SAUNDERS' 
MEDICAL  HAND-ATLASES. 

«o^-o« 

The  series  of  books  included  under  this  title  are  authorized  translations 
into  English  of  the  world-famous 

Lehmann  Medicinische  Handatlanten, 

which  for  scientific  accuracy,  pictorial  beauty,  compactness,  and 
cheapness  surpass  any  similar  volumes'  ever  published. 

Each  vojume  contains  from  50  to  100  colored  plates,  besides  numer- 
ous illustrations  in  the  text.  The  colored  plates  have  been  executed  by  the 
most  skilful  German  lithographers,  in  some  cases  more  than  twenty  im- 
pressions being  required  to  obtain  the  desired  result.  Each  plate  is  accom- 
panied by  a  full  and  appropriate  description,  and  each  book  contains  a  con- 
densed but  adequate  outline  of  the  subject  to  which  it  is  devoted. 

One  of  the  most  valuable  features  of  these  atlases  is  that  they  offer  a 
ready  and  satisfactory  substitute  for  clinical  observation.  Such  ob- 
servation, of  course,  is  available  only  to  the  residents  in  large  medical  centers; 
and  even  then  the  requisite  variety  is  seen  only  after  long  years  of  routine 
hospital  work.  To  those  unable  to  attend  important  clinics  these  books 
will  be  absolutely  indispensable,  as  presenting  in  a  complete  and  con- 
venient form  the  most  accurate  reproductions  of  clinical  work,  interpreted 
by  the  most  competent  of  clinical  teachers. 

While  appreciating  the  value  of  such  colored  plates,  the  profession  has 
heretofore  been  practically  debarred  from  purchasing  similar  works  because 
of  their  extremely  high  price,  made  necessary  by  a  limited  sale  and  an 
enormous  expense  of  production.  Now,  however,  by  reason  of  their  pro- 
jected universal  translation  and  reproduction,  affording  international  dis- 
tribution, the  publishers  have  been  enabled  to  secure  for  these  atlases  the 
best  artistic  and  professional  talent,  to  produce  them  in  the  most 
elegant  style,  and  yet  to  offer  them  at  a  price  heretofore  unapproached 
in  cheapness.  The  great  success  of  the  undertaking  is  demonstrated 
by  the  fact  that  the  volumes  have  already  appeared  in  nine  different 
languages — German,  English,  French,  Italian,  Russian,  Spanish,  Danish, 
Swedish,  and   Hungarian. 

The  same  careful  and  competent  editorial  supervision  has  been 
secured  in  the  English  edition  a>  in  the  originals.  The  translations  have 
been  edited  by  the  leading  American  specialists  in  the  different  sub- 
jects. The  volumes  are  of  a  uniform  and  convenient  size  (5  x  7^  inches), 
and  are  substantially  bound  in  cloth. 

(For  List  of  Books,  Prices,  etc.  see  back  coverJ 

Pamphlet  containing  specimens  of  the  Colored  Plates 

sent  free  on  application. 


QL> ' 


ATLAS 

OF   THE 

EXTERNAL  DISEASES  OF  THE  EYE 

INCLUDING   A   BRIEF   TREATISE 

ON    THE 

PATHOLOGY   AND   TREATMENT 

BY 

PROF.    DR.    O.    HAAB 

of  Zurich 


AUTHORIZED  TRANSLATION  FROM  THE  GERMAN 


EDITED    BY 


G.  E.  deSCHWEINITZ,  A.M.,  M.  D. 

Professor   of  Ophthalmology    in    the    Jefferson    Medical    College,    Philadelphia 
Consulting  Ophthalmologist    to    the    Philadelphia   Polyclinic;    Ophthal- 
mic Surgeon  to  the  Philadelphia  Hospital  and  to  the  Ortho- 
pedic Hospital  and  Infirmary  for  Nervous  Diseases. 


With  76  Colored  Plates  and  6  Engravings 


PHILADELPHIA 
W.    B.    SAUNDERS 

925  Walnut  Street 
1899 


Copyright,  1899, 
By  W.  B.  SAUNDERS. 


ELECTROTYPED.BY  PRESS  OF 

WESTCOTT  &  THOMSON,    PHILADA,  W.    B,    SAUNDERS.    PHILADA. 


VjIaJ 
100 


EDITOR'S    PREFACE 


This  volume  forms  an  excellent  companion-book  to 
Professor  Haab's  "  Atlas  of  Ophthalmoscopy  and  Oph- 
thalmoscopic Diagnosis,"  and  is  exactly  what  might  be 
expected  from  an  author  of  such  wide  clinical  experience 
and  trained  observation.  Beginning  with  the  examina- 
tion of  the  eye — that  is,  with  functional  testing — the 
student  is  easily  and  gradually  led  from  one  examination 
to  another,  and  made  familiar  with  the  best  methods  of 
investigating  the  organ  of  sight  for  the  detection  of  mor- 
bid processes.  Following  this  are  the  chapters  on  dis- 
eases of  the  eye,  the  most  important  of  which  are  clearly 
described  and  the  best  therapeutic  measures  briefly  re- 
corded. As  Professor  Haab  himself  has  pointed  out, 
there  is  much  difficulty  in  portraying  in  colors  the  ex- 
ternal diseases  of  the  eye ;  but,  in  spite  of  this,  he  has 
succeeded  in  furnishing  an  admirable  series  of  plates,  to 
each  one  of  which  a  brief  clinical  history  is  appended, 
which  thoroughly  illustrate  the  text.  Perhaps  it  is  not 
too  much  to  say  that  while  one  is  reading  this  manual  he 
distinctly  feels  that  he  is  in  the  atmosphere  of  a  large 
clinic. 


8  EDITOR'S  PREFACE. 

The  Editor  has  compared  the  translation  with  the  origi- 
nal, and  can  testify  that  although  it  is  not  precisely 
literal,  it  is  none  the  less  singularly  accurate,  and  always 
conveys  with  faithfulness  the  author's  meaning.  Occa- 
sional editorial  comments  are  placed  in  brackets.  It  is 
hoped  that  this  book  will  prove  of  use  not  only  to  physi- 
cians whose  opportunities  do  not  permit  them  to  see  large 
numbers  of  external  ocular  disorders,  but  also  to  teachers 
and  students  of  ophthalmology. 


PREFACE 


At  the  request  of  the  publisher  I  undertook  the  task 
of  preparing  the  present  atlas  and  accompanying  treatise, 
although  at  the  time  I  fully  appreciated  how  difficult  it  is 
to  give  a  faithful  reproduction  of  the  external  diseases  of 
the  eye.  But  after  seeing  the  work  of  Mr.  J.  Fink,  of 
Munich,  at  my  clinic  last  summer,  I  became  convinced 
of  his  ability  to  accomplish  anything  within  the  range 
of  the  illustrator's  art. 

With  the  exception  of  a  few  pictures  which  I  already 
had  in  my  collection,  the  illustrations  were  all  painted 
from  nature,  the  artist  utilizing  any  suitable  cases  that 
happened  to  come  to  the  clinic.  We  therefore  had  to 
depend  largely  on  chance  for  a  complete  collection  of 
suitable  clinical  pictures ;  but  we  were  fortunate  enough 
to  obtain  and  commit  to  canvas  the  most  important  of 
such  diseases  as  lend  themselves  to  illustration. 

Some  things  which  cannot  be  satisfactorily  reproduced 
on  paper — as,  for  instance,  certain  corneal  lesions — were 
not  even  attempted  ;  while  other  deficiencies  in  the  collec- 
tion  are  explained   by   failure  to  secure   the  necessary 

clinical  material. 

9 


10  PREFACE. 

In  the  treatise  on  pathology  and  treatment  which 
accompanies  the  plates  I  have  confined  myself  to  essen- 
tials— above  all,  to  a  detailed  description  of  methods  of 
examination,  which  I  deemed  most  important  to  students 
and  practising  physicians.  For  this  reason  less  space  has 
been  devoted  to  operative  technique  and  more  to  the 
pathology  and  to  non-operative  treatment. 

I  wish  to  express  my  sincere  appreciation  of  the  pub- 
lisher's efforts  to  bring  the  atlas  up  to  the  standard  of  the 
excellent  series  of  which  it  forms  a  part. 

O.  HAAB. 


CONTENTS 


PAGE 

Examination  of  the  Eye  in  Disease 17 

1.  External  Inspection  by  Daylight 20 

2.  Tension  of  the  Eyeball      36 

3.  Testing  Acuteness  of  Vision 38 

4.  Examination  with  Lateral  Illumination 46 

5.  Examination  by  Transmitted  Light      48 

6.  Examination  with  the  Inverted  Image 50 

7.  Examination  with  the  Upright  Image 50 

8.  Accommodation 50 

9.  Measuring  the  Field  of  Vision 55 

10.  Measuring  the  Light-sense :    .    .    .     59 

11.  Testing  the  Color-sense      60 

12.  Examination  for  Disturbances  of  Mobility 62 

Detection  of  Malingerers      74 

Diseases  of  the  Lachrymal  Apparatus  (Plates  1-3) 78 

Dacryostenosis,  Dacryocystitis,  Ectasia  of  Lachrymal  Sac. 

Diseases  of  the  Eyelids  (Plates  4-10) 92 

1.  Inflammations. 

Herpes  Zoster  and  Erysipelas      92 

Eczema 94 

Seborrhea 97 

Hordeolum 100 

Chalazion 102 

2.  Anomalies  in  the  Shape  and  Position  of  the  Eyelids    ....  104 

Congenital  Ptosis 104 

Ectropion 105 

Entropion 106 

3.  Injuries  of  the  Eyelids 107 

4.  Tumors  of  the  Eyelids 108 

11 


12  CONTENTS. 

PAGE 

Diseases  of  the  Conjunctiva  (Plates  11-19) 109 

A.  Confluent  Inflammations. 

1.  Simple  Catarrhal  Conjunctivitis 109 

2.  Follicular  Conjunctivitis 112 

3.  Gonorrheal  Conjunctivitis 113 

4.  Diphtheritic  Conjunctivitis 119 

5.  Trachoma 121 

6.  Spring-conjunctivitis 126 

B.  Circumscribed  Inflammations. 

7.  Eczematous,  Phlyctenular,  or  Scrofulous  Conjunctivitis     .    .    129 

8.  Pemphigus 134 

9.  Variola 135 

10.  Acne 135 

11.  Scleritis 135 

12.  Tuberculosis      136 

13.  Syphilomata  and  Leprosy 138 

Injuries  of  the  Conjunctiva. 

1.  Foreign  Bodies 138 

•J.  Ecchymoses 139 

3.  Burns 139 

Pterygium 140 

Tumors  of  the  Conjunctiva 141 

Diseases  of  the  Cornea  I  Plates  20-28) 143 

A.  Diffuse  Inflammations. 

1.  Parenchymatous  Keratitis 143 

B.  Circumscribed  Inflammations. 

2.  Eczematous  Keratitis 149 

3.  Herpes  Corneae 155 

Herpes  Zoster 155 

Herpes  Febrilis 156 

4.  Hypopyon  Keratitis 159 

5.  Catarrhal  Ulcer 167 

Injuries  of  the  Cornea 168 

Malformations  of  the  Cornea 169 

Diseases  of  the  Sclera  (Plate  29) 171 

1.  Inflammations  of  the  Sclera 171 

•J.    Injuries  of  tin- Sclera 173 

Diseases  of  the  Iris  and  Ciliary  Body  |  Plates  •':<»  ami  31 ) 177 

1.  Inflammations     177 

Symptoms  of  Iritis 177 


CONTENTS.  13 

PAGE 

Symptoms  of  Cyclitis 179 

Causes  of  Iritis 181 

Sympathetic  Ophthalmitis 184 

2.  Injuries  of  the  Iris \s7 

3.  Tumors  of  the  Iris  and  Ciliary  Body 188 

Diseases  of  the  Lens  (Plates  32-34) 188 

Cataract 189 

a.  Partial  Stationary  Cataracts. 

1.  Anterior  Polar  Cataract 191 

2.  Posterior  Polar  Cataract 191 

3.  Perinuclear,  Lamellar  Cataract 192 

h.  Progressive  Cataracts. 

1.  Senile  Cataract 193 

2.  Congenital  Cataract 195 

3.  Traumatic  Cataract 195 

4.  Complicated  Cataract 196 

Dislocation  of  the  Lens 197 

Diseases  of  the  Vitreous  Body  (Plate  35) 199 

Glaucoma  (Plate  36) 203 

1.  Primary  Glaucoma 203 

a.  Inflammatory  Glaucoma 204 

b.  Non-inflammatory  or  Simple  Glaucoma 207 

Infantile  Glaucoma      208 

2.  Secondary  Glaucoma 211 

Diseases  of  the  Orbit  (Plates  37-40;  Figs.  O,  D,  E,  F) 211 

1.  Inflammations 211 

2.  Injuries  of  the  Orbit 215 

3.  Tumors  of  the  Orbit 216 


LIST  OF  ILLUSTRATIONS. 


Plate    1.  Dacryocystitis. 

Plate    2.  Dacryocystitis  with  Rupture  of  the  Abscess  through  the 

Skiu. 
Plate    3.  Lachrymal   Fistula  on   the  Eight  Side ;    Ectasia  of  the 

Lachrymal  Sac  on  the  Left;  Bilateral  Epicanthus. 
Plate    4,  a.       Papular  Syphilide. 
Plate    4,  b.       Eczematous  Blepharitis. 
Plate    5.  Meibomian  or  Internal  Hordeolum. 

Plate    6,  a.       Eczematous  Blepharitis. 

Plate    6,  b.       Molluscum  Contagiosum  and  External  Hordeolum. 
Plate    7,  a-c.   Multiple  Chalazion. 
Plate    8.  Blepharochalasis  on  both  Sides. 

Plate    9.  Blepharochalasis.     Ptosis.     Epicanthus. 

Plate  10.  Subcutaneous  Hemorrhage  in  the  Lids  after  Fracture  of 

the  Base  of  the  Skull. 
Plate  11,  a,  b.  Dermoid  Tumor. 

Plate  12.  Gonorrheal  Conjunctivitis  in  the  New-born. 

Plate  13,  a,  b.  Diphtheritic  Conjunctivitis. 
Plate  14,  a.      Trachoma  of  the  Lower  Lid. 

Plate  14,  b.       Subconjunctival  Ecchymoses  (Hyphema  Conjunctivae). 
Plate  15,  a-d.  Spring-conjunctivitis.' 
Plate  16,  a.       Chaff-particle  at  the  Corneal  Margin. 
Plate  16,  b.       Pterygium. 

Plate  17.  Eczema  of  the  Conjunctiva  and  of  the  Face. 

Plate  18,  a.      Marginal  Eczema-pustule. 
Plate  18,  b.       Epithelioma  of  Cornea  and  Conjunctiva. 
Plate  19,  a,  b.  Lime-burn  of  the  Conjunctiva  and  Cornea. 
Plate  20.  Herpes  Zoster  Ophthalmicus. 

Plate  21.  Foreign  Body  on  the  Cornea  and  Dermoid  Cyst  of  the 

Orbit. 
Plate  22.  Eczema  of  the  Cornea  and  Conjunctiva  on  Both  Sides. 

Plate  23,  a.      Perforation  of  the  Cornea  by  an  Eczematous  Ulcer,  with 

Adhesion  of  the  Iris. 

15 


L6 


LIST  OF  ILLUSTRATIONS. 


Plate  23,  b.  Macula  of  the  Cornea. 

Plate  24.  Herpes  Corneae  Febrilis. 

Plate  25,  ".  Berpes  Corneae  Febrilis. 

Plate  25.  b.  Hypopyon-keratitis. 

Plate  26,  <k  b.  Serpiginous  Ulcer  of  the  Cornea  :  Pterygium. 

Plate  27.  Suppuration  of  the  Cornea  from  Serpiginous  Ulcer;  Pan- 
ophthalmitis. 

Plate  28,  a.  Trachoma,  with  Pannus  of  the  Cornea. 

Plate  28,  b.  Phthisis  Bulbi  Anterior ;  Calcareous  Degeneration  of  the 
Cornea. 

Plate  28,  c.  Parenchymatous  Keratitis 

Plate  29,  ".  Scleritis. 

Plate  29,  b.  Sequelae  of  Scleritis  and  Sclerotizing  Keratitis. 

Plate  30,  a.  Sarcoma  of  the  Iris. 

Plate  30,  b.  Syphilitic  Iritis. 

Plate  31.  Syphilitic  Condyloma  tons  Iritis. 

Plate  32.  a.  Senile  Cataract. 

Plate  32,  b.  Traumatic  Cataract. 

Plate  33,  a,  6.  Zonular  Cataract. 

Plate  33.  Incipient  Senile  Cataract. 

Plate  34,  a.  Anterior  Polar  Cataract. 

Plate  34,  b.  Subconjunctival  Displacement  of  the  Lens. 

Plate  35,  a.  Suppuration  in  the  Vitreous,  caused  by  a  Piece  of  Iron. 

Plate  35,  b.  Panophthalmitis  from  the  Entrance  of  a  Piece  of  Iron 
into  the  Vitreous. 

Plate '36,  a.  Acute  Glaucoma. 

Plate  36,  b.  Laceration  of  the  Iris  and  Lens  by  a  Spicule  of  Iron. 

Plate  37.  Sarcoma  of  the  Choroid. 

Plate  38,  a,  b.  Glioma  of  the  Retina. 

Plate  39.  Exophthalmos. 

Plate  40.  Pulsating  Exophthalmos  of  the  Left  Eye. 


FIGURES  IN   TEXT. 

PAGE 

Fig.  A.  Diagram  showing  Action  of  External  Eye-muscles     ....  63 
Fig.  B.  Diagram  showing  Double  Images  in  Paralysis  of  the  Supe- 
rior Rectus,  Inferior  Oblique,  Inferior  Rectus,  and  Supe- 
rior Oblique  «if  the  Left  Eye TO 

FIG.  C.  Dermoid  Cyst  of  the  Orbit      216 

Fig.  D.  Bone-cyst,  due  to   Ectasia  of  the   Ethmoid  Cells,  Frontal 

Sinus,  and  Nasal  Cavity 218 

Fig.  E.  Angioma  of  the  Orbit 220 

Fig.  F.  Cancer  of  the  Upper  Maxilla  and  Orbit 223 


(T* 


EXTERNAL  DISEASES  OF  THE  EYE. 


EXAMINATION  OF  THE  EYE  IN  DISEASE. 

In  ophthalmology,  as  in  other  fields  of  medical  activity, 
success  in  diagnosis  depends,  above  all,  upon  the  expe- 
rience of  the  diagnostician.  Only  second  in  importance, 
however,  is  a  definite,  systematic  routine  in  examination, 
the  faithful  observance  of  which  will  eventually  become 
second  nature  to  the  surgeon,  so  that  he  will  almost  in- 
stinctively apply  all  the  various  methods  of  examination 
one  after  the  other  in  their  proper  order. 

Owing  to  the  ease  with  which  both  the  exterior  and  the 
interior  of  the  eyeball  can  be  seen,  the  great  majority  of 
its  external  as  well  as  its  internal  alterations  and  diseases 
can  be  determined  with  absolute  certainty,  usually  at  the 
first  examination.  Those  eases  in  which  the  diagnosis 
must  be  confirmed  or  corrected  by  observing  the  course 
of  the  disease  or  the  effect  of  treatment  (ex  juvantibus) 
form  a  small  minority;  and  in  only  a  very  few  disease- 
processes  is  the  true  interpretation  obtained  from  the 
autopsy.  The  ophthalmic  surgeon  is  rarely  forced  to 
conclude  his  diagnosis  with  the  phrase  "  Sectio  docebit" 
— a  virtual  admission  of  failure. 

Nevertheless  the  practice  of  ophthalmology,  if  based 
on  the  proper  recognition  of  disease,  is  by  no  means 
without  its  difficulties.  The  physician  is  confronted  and 
perhaps  misled  by  a  multitude  of  processes  differing  but 
slightly  from  each  other,  by  a  rich  variety  of  clinical 
pictures,  and  by  the  difficulty  of  recognizing  many  im- 
portant pathologic  conditions  in  the  eye,  either  because 
the  lesions  to  be  looked  for  are  very  small  or  because 
they  are  apparently  unimportant — that  is,  they  present 
well-nigh  imperceptible  deviations  from  the  normal. 
2  17 


18  EXTERNAL  DISEASES  OF  THE  EYE. 

To  this  diversity  of  phenomena,  on  the  one  hand,  and 
to  the  extraordinary  demands  on  the  observer's  eyesight, 
on  the  other,  must  be  attributed  the  many  cases  of  mis- 
taken diagnosis  which,  in  spite  of  the  ease  and  clearness 
with  which  both  the  exterior  and  the  interior  of  the  eye 
can  be  seen,  unfortunately  occur  in  this,  as  in  other 
brandies  of  medicine.  The  most  deplorable  result  of 
such  diagnostic  error  is  blindness,  which  occurs  only  too 
frequently,  as,  for  instance,  in  cases  of  glaucoma. 

It  is  therefore  important  for  the  student  of  medicine  to 
familiarize  himself  as  much  as  possible  with  ophthal- 
mology, as  he  is  likely  at  any  time,  as  a  practising  physi- 
cian, to  be  obliged  to  resort  to  ophthalmic  surgery,  which 
he  will  then  realize  is  as  vital  a  branch  of 'medicine  as 
surgery  or  obstetrics,  for  to  many  people  blindness  is  as 
great  a  calamity  as  death  itself. 

The  student  will  readily  appreciate  the  importance  of  a 
thorough  training  in  ophthalmology  if  he  will  reflect  for  a 
moment  that  it  is  often  impossible  to  refer  an  eye-patient 
to  a  specialist,  unless  one  happens  to  reside  in  the  same 
place  or  in  the  immediate  neighborhood.  To  be  sure,  eye- 
patients  are  often  transportable — i.  e.,  able  to  travel — but 
not  always,  when  it  happens  that  the  morbid  process, 
as,  for  example,  in  certain  forms  of  glaucoma,  has  much 
debilitated  the  subject  by  pain,  vomiting,  etc.;  or  when  a 
new-born  infant  is  concerned,  whom  the  parents  object  to 
send  on  a  journey  ;  or  when  certain  external  conditions, 
such  as  advanced  age,  poverty,  etc.,  make  travel  impos- 
sible ;  or,  finally,  when  the  ocular  disorder  is  accom- 
panied by  other  grave  disturbances  which  put  travelling 
out  of  the  question. 

In  many  cases  the  loss  of  time  alone  incurred  by  con- 
sulting a  specialist  residing  at  a  distance  might  entail 
irreparable  injury  on  account  of  the  fatal  delay  in  apply- 
ing the  proper  remedies  and  the  consequent  ravages  of  the 
disease  in  the  delicate  organ,  which  the  most  skilful  hand 
is  unable  afterward  to  remedy. 

-Mention  has  been  made  of  the  great  demands  on  the 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         19 

examiner's  eyesight  in  the  study  of  ocular  affections  ;  the 
same  remark  applies  to  the  actual  practice  of  ophthal- 
mology. It  is  therefore  quite  in  order,  before  beginning 
a  detailed  description  of  the  most  efficient  method  of  ex- 
amination, to  devote  a  few  words  to  the  most  essential 
requisite  in  such  an  examination — the  visual  apparatus  of 
the  observer.  I  have  often  observed  that  medical  men 
take  up  ophthalmology  as  a  specialty  without  fully  real- 
izing the  prime  importance  of  good  eyesight  in  this 
branch  of  medicine. 

Although  the  use  of  a  lens  (corneal  loupe)  may  to  some 
extent  correct  defective  eyesight  in  the  examination  of  the 
anterior  portion  of  the  eye,  yet  in  working  with  the  oph- 
thalmoscope imperfect  visual  acuity  is  always  a  distinct 
disadvantage.  A  person  with  marked  astigmatism  suffers 
most  in  this  respect  both  in  examining  the  exterior  and  the 
fundus  of  a  diseased  eyeball ;  it  is  only  with  the  greatest 
difficulty  that  he  is  able  to  see  the  most  essential  points, 
if  they  do  not  escape  him  altogether. 

A  moderate  degree  of  myopia  (1-3  D)  is  less  trouble- 
some than  hypermetropia.  As  age  advances  the  hyper- 
metropic eye  requires  convex  glasses,  which  are  a  great 
obstacle  to  delicacy  in  examining  and  operating ;  or,  at 
least,  are  very  unpleasant  and  multiply  the  difficulties  of 
the  task. 

Binocular  vision,  the  power  to  see  with  both  eyes  at 
once,  is,  of  course,  essential  for  obtaining  a  correct  stereo- 
scopic picture ;  and  as  the  diagnosis  of  many  pathologic 
changes  in  the  eye  depends  on  a  correct  understanding  of 
the  appearances  in  the  fundus,  one  who  is  able  to  study 
them  with  one  eye  only  is  thereby  deprived  of  a  very 
important  aid,  especially  when  a  rapid  survey  of  a  given 
phenomenon  in  all  its  dimensions  is  desired.  Again  the 
lens  can  throw  itself  into  the  breach  and  make  up  for  the 
absence  of  binocular  vision  ;  but  in  operating  its  use  is  out 
of  the  question,  or  is  at  least  a  disadvantage.  By  long 
practice  he  who  has  but  one  sound  eye  at  his  disposal, 
or  whose  eyes  do  not  work  together  properly,  may  pbs- 


20  EXTERNAL   DISEASES  OF  THE  EYE. 

sibly  overcome  the  defect  to  some  extent;  but  he  will 
almost  certainly  be  outstripped  in  the  race  by  better 
equipped  competitors.  Even  if  he  has  succeeded,  after 
much  trouble,  in  correcting  the  defect  by  long  practice 
and  by  the  use  of  various  appliances,  cases  of  unusual 
difficulty  either  in  operating  or  exploring  will  always 
present  themselves,  in  which  he  will  be  more  or  less 
at  a  disadvantage  compared  with  one  whose  eyesight  is 
perfect. 

Although  I  have  known  oculists  who  practised  their 
profession  successfully  in  spite  of  aggravated  astigmatism 
or  the  virtual  loss  of  one  eye,  my  advice  to  a  medical  man 
who  contemplates  devoting  himself  to  ophthalmology  is  no 
less  emphatic,  not  to  do  so,  unless,  upon  careful  examina- 
tion, it  is  found  that  each  eye  has  at  least  1.5  the  visual 
acuity  of  the  average  normal  eye,  that  binocular  vision  is 
perfect,  and  that  he  is  not  color-blind.  Any  one  who, 
lacking  these  requisites,  takes  up  ophthalmology  as  a 
specialty,  will  find  it  difficult  to  attain  proficiency  and 
will  be  in  constant  danger  of  being  distanced  by  men  who 
are  better  equipped  by  nature. 

To  introduce  the  student  to  the  study  of  ophthalmology 
we  shall  first  give  a  detailed  description  of  the  method* 
which  lie  at  the  foundation  of  the  examination  for  diag- 
nostic purposes.  After  that  the  plan  of  study  will  consist 
chiefly  of  accurate  descriptions,  with  illustrations,  of  patho- 
logic processes  and  their  numerous  varieties. 

The  first  step  in  the  examination  of  an  eye-patient,  be 
the  disease  external  or  internal,  is 


i.  External  Inspection  by  Daylight. 

The  patient  is  placed  on  a  chair  facing  a  window,  in 
a  strong  light,  the  observer  standing  with  his  back  to  the 
window.  It  is  better  not  to  take  the  history  until  after 
the  examination,  except  the  most  necessary  points  or  such 
as  the  patient  cannot  be  prevented  from  giving,  as  the 
correct   interpretation   of  objective   signs  would   be   dis- 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         21 

turbed  by  incorrect  data  and  explanations  on  the  part 
of  the  patient. 

The  entire  person  is  first  rapidly  inspected,  and  any 
departure  from  the  normal  noted.  Abnormal  appearance 
of  the  face — pallor,  redness,  or  yellow,  cachectic  discolora- 
tion— the  signs  of  rapid  loss  of  flesh,  etc.,  must  be  carefully 
noted.  It  is  especially  important  to  look  for  traces  of 
disease  in  the  exposed  parts  of  the  skin,  the  face,  the  neck 
and  throat,  and  the  hands.  This  examination  should  in- 
clude a  search  for  recent  or  old  exanthemata,  especially 
eczema,  syphilitic  eruptions,  etc.;  or  the  scars  of  such 
skin-lesions.  Next  the  examiner  looks  for  signs  of  injury 
to  the  integument,  as  abrasions,  contusions,  subcutaneous 
hemorrhages,  or  wounds  of  any  description,  and  should  be 
careful  not  to  forget  them,  if  found,  especially  when  the 
eye  is  said  to  have  been  injured.  This  examination  must 
never  be  neglected  in  cases  which  from  the  beginning  come 
to  the  notice  of  courts  of  law,  or  in  which  an  actionable 
accident  is  alleged  as  the  cause  of  the  disorder. 

The  condition  of  glands  under  the  jaw  and  at  the  angle, 
at  the  back  of  the  neck,  and  in  front  of  the  ear  should  be 
investigated  to  determine  if  there  is  any  swelling  or  any 
sears  or  fistulse.  Joint-affections  and  old  ankyloses  should 
also  claim  attention. 

Alopecia,  if  of  recent  development,  is  important  as 
pointing  to  the  possible  presence  of  syphilis^  which  so  often 
plays  a  part  in  diseases  of  the  eye.  Eczema  and  seborrhea 
of  the  hairy  seal])  are  also  valuable  diagnostic  signs,  as  will 
be  explained  more  in  detail  later  on. 

The  result  of  this  preliminary  inspection  of  the  ex- 
posed portions  of  the  skin  and  of  the  glandular  system, 
etc.,  will  determine  whether  it  is  necessary  to  examine  the 
skin  of  the  entire  body  ;  in  any  case  this  examination,  as 
well  as  that  of  the  body  in  general,  can  wait ;  and  atten- 
tion is  next  directed  to  the  exterior  of  the  eye.  It  is 
advisable  not  to  examine  the  eye  at  short  range  at  first,  as 
certain  general  appearances,  such  as  traces  of  eruptions, 
slight  differences  between  the  right  and  left  sides  of  the 


22  EXTERNAL  DISEASES  OF  THE  EYE. 

face,  differences  in  the  palpebral  fissures  of  the  two  eyes 
and  in  the  size  and  shape  of  the  eyeballs,  are  best  appre- 
ciated from  a  distance. 

If  there  is  a  squint  of  one  eye,  we  test  the  mobility  of 
the  eyeball  by  making  the  patient  look  to  either  side  and  up 
and  down.  The  same  examination  is  repeated  if  one  eye 
is  more  prominent  than  its  fellow,  a  condition  called  pro- 
trusion. Under  certain  circumstances  testing  the  mobility 
may  have  to  be  postponed,  and  inspection  is  continued. 

The  region  of  the  lachrymal  sac  (to  the  nasal  side  of  the 
inner  canthus)  is  first  examined.  If  the  least  degree  of 
swelling,  and  especially  if  redness,  is  observed,  it  ought  to 
suggest  catarrh  or  inflammation  of  the  lachrymal  sac — in 
short,  dacryo8tenosis,  which  must  then  be  borne  in  mind. 
The  abnormal  contents  of  the  sac  can  often  be  squeezed  out 
by  pressure  with  the  finger  through  the  lachrymal  puncta, 
even  when  there  is  no  visible  swelling  of  the  lachrymal 
sac,  and  only  a  slight  increase  of  fluid  in  the  eye — so- 
called  "  swimming n  of  the  eye — to  suggest  defective  dis- 
charge of  the  lachrymal  fluid. 

Dacrvostenosis  cannot  be  diagnosed  with  certainty  with- 
out flushing  the  lachrymal  duct,  a  procedure  which  is  best 
undertaken  at  the  end  of  the  examination.  We  shall  dis- 
cuss this  point  in  detail  when  we  come  to  treat  of  disease 
of  the  lachrymal  apparatus. 

Before  proceeding  to  the  study  of  the  eye  itself  and  any 
defects  there  may  be  in  it,  a  rapid  inspection  is  made  of 
the  eyelids  for  the  purpose  of  noting  any  abnormal  condi- 
tions, such  as  misplaced  cilia  or  deformed  or  diseased 
palpebral  margins  ;  for  these  structures  are  frequently  the 
scat  of  disease.  It  should  be  carefully  noted  whether  the 
lachrymal  puncta  are  in  their  proper  places  (at  the  nasal 
extremity  of  the  lid)  and  whether  they  communicate  with 
the  tear-lake  (lacus  lacrimalis). 

If  the  eye  is  opened  naturally,  the  region  of  the  palpe- 
bral fissure  is  inspected  without  touching  the  lids.  If 
the  palpebral  fissure  is  too  narrow,  the  lids  may  be  gently 
drawn  apart  and  the  inner  surface  of  the  lower  lid  ex- 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         23 

arained  by  drawing  the  lid  downward,  if  the  previously 
found  conditions  make  it  desirable. 

The  inner  surface  of  the  upper  lid  may  also  be  ex- 
amined at  this  point  by  everting  the  lid.  Often,  however, 
it  is  advisable  to  defer  this  procedure  or  even  to  omit  it 
altogether,  since  it  may  not  be  necessary,  if  the  disease  is 
internal,  and  would  interfere  with  the  tests  for  visual 
acuity,  or  at  any  rate  unnecessarily  distress  the  patient. 
In  deep  wounds  of  the  eyeball  the  act  may  be  downright 
harmful. 

Eversion  of  the  eydid  is  effected  as  follows  :  The  left 
thumb,  held  with  its  volar  surface  nearly  in  a  horizontal 
plane,  is  pressed  on  the  eyelid  a  little  below  the  eyebrow 
so  as  to  draw  the  skin  gently  upward,  enough  to  obliterate 
the  wrinkles  (in  elderly  people),  and  at  the  same  time  to 
separate  the  palpebral  margin  from  the  eyeball.  Next  the 
lid  is  seized  with  the  thumb  and  index-finger  of  the  right 
hand,  either  by  the  cilia,  or,  if  there  are  none,  by  a  fold 
of  skin  near  the  margin,  and  drawn  downward,  while  the 
patient  is  told  to  look  down  as  much  as  possible.  The  lid 
is  now  taut  and  can  be  turned  over  the  left  thumb, 
|  which  is  at  the  same  time  moved  downward,  pressing  the 
upper  edge  of  the  tarsus  back  and  down,  while  the  right 
hand  draws  the  lower  margin  of  the  lid  forward  and 
upward.  If  it  is  found  impossible  to  evert  the  lid  in  this 
way,  a  probe  or  glass  rod  may  be  substituted  for  the  left 
thumb.  This  will  enable  one  to  accomplish  it  even  when 
the  patient  is  awkward  and  fails  to  look  down,  or  shuts 
his  eyes  convulsively.  The  more  gentle  the  operation  the 
better  it  will  succeed  ;  and  the  clumsier  the  hand  of  the 
operator  the  more  violent  will  be  the  struggles  and  the 
greater  the  difficulties.  The  lid  can  also  be  everted  with 
one  hand  ;  but  this  method  is  not  to  be  recommended,  as 
it  is  too  severe. 

While  the  inspection  of  the  eyeball  and  of  the  inner 
surfaces  of  the  eyelids  usually  presents  no  special  diffi- 
culties in  the  adult,  it  is  a  much  more  troublesome  matter 
in  the  case  of  new-born  infants  and  children,  and  requires 


24  EXTERNAL    DISEASES  OF  THE  EYE. 

certain  special  precautions  which  merit  particular  de- 
scription. I  have  often  observed  unsatisfactory  results  in 
the  examination  and  treatment  of  children  which  were  due 
solely  to  the  inexperience  and  want  of  skill  of  the  operator, 
ignorant  of  the  proper  methods  of  overcoming  the  resist- 
ance which  the  little  sufferers  usually  offer  to  the  manipu- 
lations. Here  again  the  rule  is  to  conduct  the  examina- 
tion with  firmness  indeed,  but  with  all  possible  forbearance, 
not  only  because  the  struggles  increase  in  proportion  to 
the  want  of  delicacy,  but  also  because  a  sudden  wrenching 
apart  of  the  convulsively  closed  eyelids  is  apt  to  result  in 
serious  injury  to  the  cornea  and  in  lacerations  of  the  outer 
canthus  ;  or  the  fissures  in  the  outer  canthus  caused  by  the 
action  of  the  lachrymal  fluid,  a  frequent  cause  of  blepharo- 
spasm in  children,  are  aggravated  and  thereby  tend  to  en- 
hance the  spasm,  which  in  turn  delays  recovery. 

In  order  to  examine  and  treat  with  comfort,  safety, 
and  despatch  children  up  to  the  age  of  ten  years,  the  first 
step  is  to  put  them  into  the  proper  posture.  The  ope- 
rator takes  his  position  so  that  he  has  the  window  or 
lamp  to  his  right  or  left ;  the  nurse  or,  if  she  is  a  sensible 
woman,  the  mother  sits  opposite  him,  holding  the  child's 
legs  under  one  arm.  The  child's  back  is  supported  on 
the  nurse's  lap  and  its  head  rests  on,  or  is  held  between, 
the  operator's  knees  (which  he  has  previously  covered 
with  a  towel).  (In  the  case  of  new-born  children  care 
must  be  taken  not  to  exert  too  great  pressure  on  the 
head.)  After  the  nurse  has  secured  both  the  child's 
hands  the  examination  can  proceed  quietly  and  without 
distressing  the  little  one,  the  light  falling  full  on  it>  lace. 

First,  the  eyes  are  carefully  dried  with  absorbent  cotton. 
Wet,  slippery  eyelids  cannot  he  separated  either  in  adults 
or  in  children,  because  the  fingers  cannot  secure  a  hold 
without  the  use  of  such  force  as  to  provoke  spasm.  In 
many  cases  it  is  an  advantage  to  wrap  the  fingers  with 
gauze  before  attempting  to  separate  the  eyelids.  If  with 
all  these  precautions  it  is  found  impossible  to  separate  the 
lids  on  account  of  swelling  or  spasm,  or  both,  they  should 


EXAMINATION  OF  THE  EYE  TN  DISEASE.         25 

be  gently  and  carefully  drawn  apart  with  Desmarre's  lid- 
elevator,  care  being  taken  that  the  surface  opposed  to  the 

eyeball  is  perfectly  smooth,  so  as  to  avoid  injuring  the 
cornea.  The  instrument  must,  of  course,  be  absolutely 
clean.  One  elevator  for  the  upper  lid  is  usually  all  that 
is  needed.  If,  as  often  happens  in  private  practice,  there 
is  no  elevator  at  hand,  the  physician  can  easily  improvise 
one  from  an  ordinary  hairpin  by  bending  the  closed  end  so 
as  to  form  a  hook  about  1  cm.  long,  which  may  then  be 
carefully  inserted  under  the  eyelid.  The  hairpin  must  be 
perfectly  smooth,  and  cleaned  by  heating  before  it  is  used. 
It  is  much  better  to  resort  to  this  primitive  device  than  to 
force  the  lids  apart  with  the  unaided  lingers,  for  it  requires 
a  very  skilful  hand  to  separate  such  tightly  closed  eyelids 
in  a  struggling  child  without  an  instrument  and  without 
injuring  the  cornea. 

Eversion  of  the  eyelid,  on  the  other  hand,  is  very  easy 
in  such  children  ;  indeed,  it  often  occurs  when  it  is  not 
desired.  One  of  the  chief  uses  of  the  elevator  is  to 
prevent  eversion,  as  the  object  of  the  examination  is 
usually  to  inspect  the  cornea  and  surrounding  parts,  rather 
than  the  inner  surfaces  of  the  lids,  and  if  the  latter  are 
everted  inspection  of  the  cornea  is  impossible. 

It  is  often  necessary  to  evert  the  upper  eyelid  in  the 
examination  and  treatment  of  ophthalmia  neonatorum.  In 
such  cases  any  injury  to  the  cornea  by  the  finger-nail 
would  be  fatal ;  the  least  scratch  or  the  slightest  loss  of 
tissue  might  entail  the  loss  of  the  eye.  Hence  the  holder 
should  always  be  used  when  the  eyeball  is  inspected, 
especially  if  the  lids  are  swollen.  As  has  been  pointed 
(Hit,  inspection  of  the  inner  surface  of  the  lids  in  such  cases 
is  quite  easy,  because  the  upper  lid  usually  turns  over  as 
soon  as  the  skin  is  drawn  upward.  If  it  fails  to  do  so, 
however,  the  operator  should  wait  until  the  baby  cries, 
when  the  lid  can  easily  be  everted,  even  in  the  later  stages 
after  the  swelling  has  subsided.  Gentle  traction  of  the 
outer  canthus  toward  the  temple  assists  the  eversion  and 
tends  to  fix  the  lid  in  the  everted  position  (ectropion). 


26  EXTERNAL  DISEASES  OF  THE  EYE. 

Id  treating  children  with  severe  blepharospasm  the  fol- 
lowing must  be  borne  in  mind:  Even  after  the  operator 
lias  finally  succeeded  in  opening  the  lids  the  cornea  can- 
not always  be  seen,  because  it  is  convulsively  rolled 
upward.  Scolding  the  child  only  makes  matters  worse ; 
the  only  thing  to  do  is  to  wait  patiently,  avoiding  all 
pressure  on  the  parts  to  be  examined  and  encouraging  the 
child  by  speaking  to  it  kindly.  Usually  the  eyeball  is 
rolled  downward  sooner  or  later,  if  only  for  a  short  time, 
so  that  the  cornea  can  be  inspected.  If  the  spasm  is  so 
severe  that  the  eye  fails  to  rotate  downward  of  its  own 
accord,  a  few  drops  of  Cocain  should  be  instilled  and  the 
result  awaited.  Forceps  should  be  used  only  as  a  last 
resort ;  the  parts  are  first  thoroughly  cocainized  and  the 
instruments  must  be  handled  as  gently  as  possible. 

Always  insist  on  making  a  thorough  examination  of 
the  cornea  and  surrounding  parts  until  a  clear  view  of  the 
entire  corneal  region  has  been  obtained,  no  matter  how 
much  the  child  cries  and  struggles.  The  greatest  care  is 
necessary  not  to  exert  undue  pressure  on  the  eyeball,  for 
such  children  often  have  deep  ulcers  of  the  cornea,  which 
are  liable  to  burst  from  the  slightest  pressure  on  the  eye, 
causing  permanent  injuries  by  incarceration  of  the  iris, 
distortion  of  the  pupil,  etc.  Indeed,  rupture  of  the  floor 
of  the  ulcer  may  result  in  loss  of  the  eye  through 
infection,  especially  if  the  crystalline  lens  is  forced 
through  the  perforation,  an  accident  which  quite  easily 
may  happen. 

So  much  for  the  tech  nie  of  the  external  examination  of 
the  eye  in  children,  the  importance  of  which  cannot  be 
overestimated. 

In  the  inspection  of  the  eyeball,  to  which  we  now 
turn  our  attention,  the  following  precautions  are  to  be 
observed:  If  there  is  redness,  its  nature — /.  <\,  first,  its 
situation  and,  second,  its  color — affords  an  important 
clue  to  the  seat  of  the  disease,  and  therefore  to  the  diag- 
nosis.    The  following  points  are  to  be  noted  : 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         27 

A  practised  eye  readily  distinguishes  between  inflam- 
mation of  the  conjunctiva,  in  which  the  conjunctival 
vessels  are  congested,  and  inflammation  of  the  cornea  or 
iris,  although  both  conditions  produce  a  redness  of  the 
eye.  The  first  condition  is  called  conjunctival,  the  second 
ri/iari/,  congestion.  The  first,  or  conjunctival  congestion, 
is  characterized  by  the  fact  that  it  is  most  intense  where 
the  blood-vessels  are  most  marked—/,  c,  at  the  fornix  and 
in  its  immediate  neighborhood — and  decreases  in  intensity 
as  it  approaches  the  corneal  margin,  being  absent  in  the 
immediate  neighborhood  of  the  cornea,  so  that  there  is 
a  zone  about  5  mm.  broad  in  which  the  blood-vessels  are 
very  pale  (see  Plate  14,  a).  This  centripetal  increase  in  the 
intensity  of  the  congestion  also  appears  in  the  marked 
redness  of  the  caruncle,  situated  at  the  inner  canthus,  and 
of  the  plica  semilunaris  next  to  it  on  the  temporal  side, 
which  is  very  conspicuous  in  conjunctival  inflammation, 
and  even  at  a  distance  betrays  the  congestion  of  the  con- 
junctival vessels,  as,  for  instance,  in  acute  conjunctival 
catarrh. 

Giliary  or  circumcorneal  congestion,  on  the  contrary, 
increases  as  the  corneal  margin  is  approached,  is  most 
distinct  at  the  corneal  margin,  and  diminishes  uniformly 
at  every  point  as  the  periphery  of  the  anterior  segment  of 
the  globe  is  approached  (see  Plate  21).  The  most  dis- 
tinctly congested  corneal  zone  is  from  3  to  7  mm.  wide, 
and  corresponds  approximately  to  the  zone  least  involved 
in  pure  conjunctival  congestion.  Hence,  whereas  con- 
junctival congestion  decreases  in  intensity  as  it  approaches 
the  corneal  margin,  ciliary  congestion  diminishes  in  in- 
tensity as  it  recedes  from  the  corneal  margin.  The  blood- 
vessels concerned  in  ciliary  inflammation  are  so  deeply 
placed  and,  in  part,  so  minute  that  they  cannot  be  seen  as 
well  as  the  conjunctival  vessels. 

Disregarding  the  question  of  localization,  quite  a  dif- 
ference in  the  color  of  the  two  forms  of  congestion  may  be 
observed,  if  one  has  a  good  eye  for  color.  The  color  of  a 
conjunctival  congestion  is  yellowish  or  "  brick-red  ;"  that 


28  EXTERNAL  DISEASES  OF  THE  EYE. 

of  a  ciliary  congestion  is  more  bluish,  "pink,"  "scarlet/' 
or  "  crushed  raspberry  "  (Plates  21  and  30,  b). 

The  differences  in  color  and  in  localization  are  readily 
explained  by  the  arrangement  and  distribution  of  the 
blood-vessels  concerned  in  each  form  of  congestion. 

Conjunctival  congestion  is  due  to  abnormal  distention 
of  the  conjunctival  vessels,  barely  visible  in  the  normal 
eye  on  account  of  their  tenuity.  The  vessels  in  the 
sclerotic  portion  of  the  conjunctiva  make  their  appearance 
at  the  fornix,  and  from  all  sides  radiate  forward  and  out- 
ward toward  the  cornea,  breaking  up  into  arborizations  as 
they  proceed  and  thereby  becoming  more  and  more  minute. 
This  enlargement  furnishes  the  anatomical  explanation  of 
the  diminution  of  the  intensity  of  a  conjunctival  conges- 
tion as  it  approaches  the  cornea.  As  these  vessels  are 
very  superficial,  they  show  the  true  color  of  the  blood 
when  overfilled,  which  in  thin  layers  is  a  yellowish-red. 
Moreover,  the  conjunctival  vessels  can  be  recognized  by 
their  mobility  with  the  shifting  of  the  conjunctiva,  which 
is  but  loosely  attached  to  the  sclerotic,  especially  at  some 
distance  from  the  cornea.  This  mobility  is  often  of  ser- 
vice to  clear  up  any  doubts  about  the  nature  of  such  a 
blood-vessel. 

The  vessels  that  are  responsible  for  ciliary  or  circum- 
corneal  congestion  are  very  different  in  their  arrangement 
and  distribution.  In  the  first  place,  they  are  situated 
beneath  the  conjunctiva.  They  also  are  but  faintly  visible 
in  the  normal  eye;  in  fact,  only  the  arterioles  are  visible, 
their  accompanying  venules  becoming  manifest  only  when 
the  eye  is  inflamed.  These  arterioles  proceed  from  the 
tendons  of  the  recti  muscles,  either  singly  or  in  pairs, 
pursue  a  very  tortuous  course  in  radiating  lines  to  the 
cornea,  and  suddenly  disappear  at  points  several  milli- 
meters distant  from  the  corneal  margin,  by  entering  the 
sclerotic,  in  which  they  ramify,  and  contribute  largely  to 
the  blood-supply  of  the  ciliary  body  and  iris  (ciliary  re- 
gion). Their  points  of  entrance  into  the  sclerotic  are 
often    distinctly    tinted    and    plainly    visible.      They   are 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         29 

called  the  anterior  ciliary  vessels,  while  those  which  enter 
the  choroid  at  the  back  of  the  eyeball  are  known  as  the 
posterior  ciliary  vessels.  The  anterior  ciliary  vessels, 
before  entering  the  sclerotic,  form  ramifications,  the 
branches  of  which  anastomose  with  one  another  and 
form  a  dense  plexus  of  capillary  loops  around  the  cornea. 
Since  both  the  larger  arterial  trunks  and  their  more  minute 
branches  about  the  cornea  lie  beneath  the  conjunctiva,  be- 
tween it  and  the  sclerotic,1  they  do  not  move  with  the 
shifting  of  the  conjunctiva,  and  present  a  bluish  (lilac  or 
violaceous)  coloration,  for  the  simple  reason  that  the  con- 
junctiva acts  as  a  turbid  medium,  through  which  the  blood 
(has  a  bluish  tint.  If  a  thin  layer  of  milk  is  spread  over 
a  black  surface,  the  milk  appears  blue,  and  in  a  similar 
way  the  bluish  tint  which  we  observe  in  the  ciliary  ves- 
sels is  formed. 

It  must  be  borne  in  mind  that  the  superficial  con- 
junctival vessels  and  the  deeper  ones  of  the  episclera 
communicate  with  each  other  at  the  corneal  margin,  so 
that  the  conjunctiva  receives  some  of  its  blood-supply 
from  the  ciliary  region,  through  certain  small  branches 
which  enter  it  from  the  episcleral,  pericorneal  plexus,  and 
which  in  it  (usually  in  straight  lines)  run  backward 
(anterior  conjunctival  vessels).  This  explains  why  a 
ciliary  congestion  of  some  duration  gradually  produces 
more  or  less  hyperemia  of  the  conjunctival  system  also, 
resulting  in  a  combination  of  the  two  forms  of  congestion. 
The  converse,  however,  is  not  true  :  So  long  as  the  cornea 
is  not  affected  a  long-continued  conjunctival  congestion  is 
not  apt  to  induce  ciliary  congestion. 

The  cornea  possesses  the  peculiarity  that  as  soon  as  it 
suffers  the  least  injury  from  a  scratch-wound,  the  entrance 
of  a  foreign  body,  or  inflammation  from  any  cause,  the 
characteristic  uniform  circumcorneal  congestion   immedi- 

1  Occasionally  a  ciliary  artery,  running  from  without  and  below,  or 
from  without  (temporal)  inward  toward  the  cornea,  is  seen  lying  in  part 
within  the  conjunctiva  and  movable  with  it.  Such  a  branch  is  derived 
from  the  palpebral  arteries. 

\ 


30  EXTERNAL  DISEASES  OF  THE  EYE. 

ately  makes  its  appearance  and  thus  brings  the  lesion 
promptly  to  the  surgeon's  notice.  The  injury  or  inflam- 
mation may  be  very  slight  and  much  time  and  care  may 
be  required  for  its  detection  ;  hence,  in  every  case  of 
ciliary  congestion  the  cornea  should  be  subjected  to  a 
thorough  examination.  If  nothing  abnormal  is  found  in 
the  cornea  by  the  methods  presently  to  be  described  in 
detail,  the  cause  of  the  circumcorneal  congestion  must  be 
sought  in  irritation  or  inflammation  of  the  iris  or  ciliary 
body  (iritis,  cyclitis). 

The  foregoing  description  applies  to  general  congestions 
affecting  the  entire  area  of  distribution  of  each  system  of 
blood-vessels ;  in  addition,  we  have  to  consider  the  local 
or  circumscribed  congestions  which  occur  in  both  systems 
and  which  may  be  limited  to  a  small  area.  This  happens, 
in  the  case  of  the  conjunctiva,  when  there  is  a  local,  circum- 
scribed lesion — for  example,  a  slight  wound  or  localized  in- 
flammation in  the  form  of  an  eczema-pustule  (phlyctenule ) — 
instead  of  a  general  process  affecting  the  entire  mucous 
membrane,  as,  for  instance,  in  acute  catarrh.  Under  such 
circumstances  the  hyperemia,  which  is  superficial  and  yel- 
loicish-red  in  color,  is  limited  to  the  immediate  neighbor- 
hood of  the  injury  or  inflammatory  center  ;  or,  to  be  ac- 
curate, to  the  system  of  vessels  in  the  affected  area. 

In  a  localized  ciliary  congestion  the  appearance  is  differ- 
ent. The  color  is  darker  and  more  bluish  ;  the  vessels  can 
scarcely  be  made  out;  and  the  color  does  not  disappear 
upon  pressure  with  the  finger  on  the  eyelid  as  readily  as 
in  conjunctival  congestion.  Circumscribed  ciliary  con- 
gestion is  caused  by  inflammation  of  the  sclera,  which 
usually  is  circumscribed,  or  by  a  deep  wound  of  long 
standing  in  the  sclera. 

It  is  this  accurate  knowledge  of  the  differences  between 
the  various  forms  of  congestion  which  enables  the  practised 
examiner  to  diagnose  a  given  case  with  a  rapidity  which 
astonishes  the  beginner.  For  instance,  he  recognizes  con- 
junctival catarrh  at  a  glance  by  the  abnormal  color  at  the 
inner  canthus,  in  the  region  of  the  caruncle,  plica  semi- 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         31 

lunar  is,  and  adjoining  conjunctiva.  In  another  case,  guided 
solely  by  the  ciliary  congestion,  he  promptly  locates  the 
seat  of  the  inflammation  or  injury  in  the  cornea,  although 
the  injured  spot  is  barely  visible.  He  then  looks  for 
further  signs  of  the  morbid  process,  and  in  a  short  time 
the  diagnosis  is  formulated  and  even  the  etiology  deter- 
mined. For  instance,  a  patient  enters  the  room  with  the 
characteristic  alopecia  and  red  blotches  on  the  forehead, 
along  the  line  of  the  hair,  strongly  suggestive  of  syphilis. 
There  is  a  ciliary  congestion  in  one  eye ;  on  further  in- 
spection the  pupil  is  found  to  be  irregular  in  outline 
(instead  of  round)  from  serrations  which  encroach  on  the 
papillary  border,  and  in  the  iris  there  are  yellowish-red, 
thickened  areas.  The  diagnosis  of  syphilitic  iritis  is 
reached  in  less  time  than  it  takes  to  read  this  example. 
Not  to  anticipate,  however,  we  will  proceed  to  describe 
the  method  of  examining  that  important  structure,  the 
cornea,  which  is  such  a  frequent  seat  of  disease. 

Examination  of  the  Cornea. — We  determine  two  f 
things  :  First,  the  condition  of  the  surface;  and,  second,  the 
transparency. 

The  surface  of  the  normal  cornea  acts  like  a  small  con- 
vex mirror  in  reflecting  a  sharply  defined,  small  upright 
image  of  objects  placed  in  front  of  it  with  the  usual  dis- 
tortions incident  to  convex  mirrors.  Thus  the  image  of 
window-bars  reflected  from  the  corneal  mirror  of  a  patient 
seated  before  the  surgeon  appears  slightly  bent  (convex), 
but  clear-cut  and  distinct.  This  image  of  the  window- 
bars  is  utilized  to  test  the  condition  of  the  corneal  surface, 
by  allowing  it  to  fall  consecutively  on  different  parts  of 
the  cornea.  The  patient  is  required  to  follow  the  uplifted 
finger  as  it  is  moved  up  and  down  and  to  either  side  while 
the  surgeon  watches  the  reflection  in  the  cornea  and  is 
able  to  detect  the  slightest  inequality  in  its  surface.  Such 
slight  irregularities  are  not  uncommon,  and  may  be  of 
several  kinds : 

1.  The  image  in  one  part  of  the  cornea,  without  being 
at   all    distorted,   may  appear  somewhat   indistinct ;   the 


32  EXTERNAL  DISEASES  OF  THE  EYE. 

.surface  is  evidently  opaque  at  this  point,  it  looks  as  if  it 
had  been  breathed  upon,  and,  like  a  moist  window-pane, 
is  a  poor  reflector.  Opacities  of  this  kind  usually  corre- 
spond to  inflammatory  areas.  Opacity  of  the  entire 
cornea  indicates  either  a  general  inflammation  or  glau- 
coma. The  precise  nature  of  such  an  opacity  will  be 
described  later;  for  the  present,  suffice  it  to  say  that  in 
many  cases  this  opacity  alone  should  lead  us  at  least 
to  suspect  glaucoma,  and  may  point  the  way  to  a  correct 
diagnosis ;  we  therefore  emphasize  the  importance  of 
noting  accurately  the  reflecting  powers  of  the  cornea. 

2.  The  image  of  the  window-bars  may  be  perfectly 
clear  and  distinct,  but  the  distortion  may  be  greater  than 
normal.  It  may  be  limited  to  a  portion  of  the  image,  or 
it  may  be  general.  In  the  first  case  the  distorted  por- 
tion of  the  image  is  usually  found  to  correspond  to  an 
area  which,  although  smooth,  is  either  depressed  below, 
or  elevated  above  the  general  level,  or  presents  a  plane 
surface.  The  latter  condition  is  sometimes  called  a 
facet. 

The  distortion  may  be  general.  Two  conditions  are 
possible.  Either  the  entire  surface  is  rough  and  irregular, 
or  beset  with  numerous  facets,  as,  for  instance,  after 
repeated  ulcerations ;  or,  more  rarely,  the  general  distor- 
tion of  the  image  is  due  to  incorrect  curvature  of  the 
entire  cornea,  giving  it  a  more  or  less  conical  shape, 
a  condition  termed  keratoconus.  The  image  is  very 
small  at  the  apex  of  the  cone  and  increases  in  width  as  it 
approaches  the  corneal  margin,  where  the  lateral  portions 
of  the  membrane  (between  the  center  and  the  margin) 
take  part  in  the  reflection.  Keratoconus  is  a  serious  dis- 
turbance to  vision  ;  it  is  most  surely  recognized  by  observ- 
ing the  nature  of  the  corneal  image — another  reason  for 
training  the  eye  in  the  study  of  corneal  changes. 

3.  Under  certain  circumstances  opacity  may  be  com- 
bined with  irregularity  of  the  surface,  as,  for  example, 
more  or  less  rough  depressions  from  recent  ulcers,  or 
opaque  elevations  from  imprisoned  foreign  bodies,  or  a 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         3o 

rough  prominence  cine  to  an  epithelial  neoplasm.  Foreign 
bodies  embedded  in  the  cornea  are  a  very  common  occur- 
rence in  practice  ;  their  presence  can  always  be  discovered 
by  the  disturbance  they  cause  in  the  corneal  reflections. 
The  following  precaution  is  needful  in  many  cases  :  Slight 
irregularities  of  the  cornea,  such  as  follow  eczema,  for  in- 
stance, are  more  easily  detected  if  the  flow  of  tears  is 
clucked  tor  a  moment;  hence,  if  it  is  very  copious,  the 
lids  must  be  held  open  and  the  fluid  allowed  to  run  off, 
before  the  inspection   is  begun. 

After  the  condition  of  the  corneal  surface  has  been  de- 
termined in  this  manner,  we  proceed  to  test  its  trans- 
parency. This  is  often  disturbed  in  morbid  processes, 
notably  in  inflammations.  Colorless  blood-corpuscles  in- 
vading the  corneal  tissue  produce  a  general  or  local 
opacity,  ranging,  according  to  the  kind  and  degree  of  in- 
flammation, from  an  almost  imperceptible,  bluish-gray  film 
to  complete  opacity,  grayish-white,  or,  if  the  inflammation 
is  purulent,  even  distinctly  yellow  in  color.  The  eye 
should  be  carefully  trained  to  recognize  the  slightest 
degree  of  yellowish  discoloration,  as  it  indicates  that  the 
disease  has  assumed  a  distinctly  purulent  character  and 
the  prognosis  is  proportionately  grave.  The  yellow  color 
of  such  an  infiltration  can  be  seen  better  by  daylight  than 
by  artificial  light. 

Other  colorations  of  a  more  reddish  hue  on  a  gray  back- 
ground sometimes  occur  in  the  cornea.  Newly  formed 
blood-vessels  enter  the  inflammatory  area  from  the  corneal 
margin  and  form  a  delicate  plexus  which  produces  a  faint 
reddish  sheen.  Usually  at  least  the  larger  branches  can 
be  seen  with  the  naked  eye. 

Another  form  of  opacity,  with  or  without  blood-vessels, 
is  produced  by  the  scars  left  by  former  infiltrations  which 
ended  in  ulceration.  Sometimes  these  cicatricial  opacities 
are  distinctly  whitish  or  grayish-white,  so  that  we  speak 
of  white  spots  or  leukomata»  When  the  dots  are  not  very 
pronounced  their  grayish  color  is  so  like  that  of  a  recent 
infiltration  that  a  beginner  finds  it  difficult  to  distinguish 

3 


34  EXTERNAL  DISEASES  OF  THE  EYE. 

between  the  two  forms ;  not  so  the  experienced  practi- 
tioner, however,  for  he  knows  that  a  recent  inflammatory 
infiltration,  whether  it  is  localized  or  diffuse,  always  has  a 
dull  surface,  whereas  an  old  macula  possesses  a  good  reflect- 
ing surface.  Once  more  the  value  of  studying  the  reflect- 
ing properties  of  the  cornea  is  exemplified,  since  it  is  im- 
portant to  be  able  to  distinguish  between  an  old  opacity 
and  a  recent  corneal  inflammation.  Opacities  of  long 
standing  usually  have  a  bluish  tint,  but  the  surest  way  to 
recognize  them  is  by  their  smooth  surface. 

With  the  growth  of  accident-insurance  the  ability  to 
determine  the  age  of  a  corneal  opacity  becomes  more  and 
more  desirable.  It  frequently  happens  that  holders  of 
accident-insurance  policies  attempt  to  ascribe  to  a  recent 
accident  an  opacity  which  has  existed  for  some  time,  in 
the  hope  of  obtaining  damages  for  it  along  with  the  recent 
injury.  The  following  example  may  serve  to  illustrate 
the  importance  of  carefully  examining  for  corneal  opacities : 
A  patient  exhibits  ciliary  congestion,  suggesting  the  prob- 
ability of  corneal  disease.  There  is,  in  fact,  a  circum- 
scribed corneal  opacity,  and  the  diagnosis  of  keratitis  seems 
plausible,  especially  as  he  complains  of  pain  in  the  eye ; 
but  on  inspection  the  opaque  area  is  found  to  be  perfectly 
smooth ;  further  examination  shows  that  the  pupil  is  not 
quite  round  and  that  the  iris  is  dull  and  discolored  ;  in 
short,  it  turns  out  to  be  a  case  of  iritis.  The  corneal 
opacity  is  due  to  a  former  inflammation  which  the  patient 
had  in  his  youth,  and  he  is,  of  course,  much  impressed 
when  we  tell  him  that  he  had  inflammation  once  before  in 
the  same  eye. 

In  persons  with  blue  or  gray  i rides,  corneal  opacities, 
being  practically  of  the  same  color  as  the  iris,  cannot  be 
readily  distinguished  except  over  the  black  pupil.  Arti- 
ficial light,  presently  to  be  described,  is  needed — indeed, 
the  information  afforded  by  lateral  illumination  is  so 
valuable  that  it  must  never  be  omitted,  even  in  the  ex- 
amination of  persons  with  dark  irides. 

In  the  mean  time,  we  continue  the  examination  by  day- 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         35 

light,  examining  the  anterior  chamber  and  its  posterior 
boundaries,  the  iris,  and  the  crystalline  lens. 

First  we  note  whether  the  anterior  chamber  is  of  nor- 
mal depth,  abnormal  depth,  or  shallow,  by  ascertaining 
the  distance  of  the  iris  from  the  cornea  in  each  eye  and 
comparing  one  with  the  other.  For  example,  the  temporal 
half  of  the  anterior  chamber  may  be  quite  shallow,  while 
the  nasal  half  is  abnormally  deep.  This  usually  indicates 
that  the  lens  is  displaced  outward  toward  the  temporal 
side.  If  this  is  the  case,  a  slight  tremor  of  the  nasal  por- 
tion of  the  iris  is  observed  when  the  eye  is  moved.  The 
tremor  may  extend  over  the  entire  iris,  especially  if  the 
lens  is  absent,  as,  for  example,  when  it  is  dislocated  into 
the  vitreous  body. 

Abnormal  contents  of  the  anterior  chamber,  such  as  a 
.grayish-yellow  or  yellow  exudate,  blood,  etc.,  must  not  be 
overlooked.  A  narrow,  yellowish  band,  or  mere  line  in 
the  lowest  portion  of  the  anterior  chamber,  indicates  the 
presence  of  pus  and  is  considered  a  serious  symptom.  The 
phenomenon  is  called  hypopyon.  Foreign  bodies  are  oc- 
casionally met  with  in  the  anterior  chamber. 

Pathologic  discolorationsof  the  iris — in  inflammation,  for 
instance — can  be  seen  much  better  by  daylight  than  by 
artificial  light,  which  is  always  more  or  less  yellow.  The 
normal  color  of  the  two  eyes  must  be  compared,  as  the 
color  of  the  two  irides  may  differ  in  health,  although 
rarely. 

Comparison  of  the  two  pupils  in  respect  to  size,  shape, 
and  reaction  to  light  is  of  the  highest  importance.  As  is 
well  known,  difference  in  the  size  of  the  two  pupils  may 
be  a  very  grave  symptom,  indicating  disease  which  may 
involve  much  more  than  the  eye  alone ;  for  example,  paresis 
or  tabes. 

The  size  of  the  pupil  is  also  affected  by  light  and  con- 
vergence. A  preliminary  examination  may  be  made  by 
alternately  illuminating  and  shading  the  eye  with  the 
hand  ;  but  in  most  cases  this  must  be  supplemented  by  an 
examination  with  artificial  light.    To  obtain  a  correct  idea 


36  EXTERNAL   DISEASES  OF  THE  EYE. 

of  the  shape  of  the  pupils  they  must  be  examined  in  a 

dark   room. 

Abnormal  coloration  of  the  pupil,  crystalline  lens,  und 
vitreous  body  is  best  seen  by  daylight.  Bluish-gray  or 
grayish-white  dots  and  streaks  in  the  pupillary  region  in- 
dicate cataract.  In  elderly  people  a  slight,  grayish  filmi- 
ness  is  sometimes  observed,  apparently  in  the  depths  of 
the  lens,  which  has  often  led  inexperienced  men  to  diagnose 
cataract ;  the  phenomenon  is  produced  by  the  increased 
reflecting  power  of  the  lens,  due  to  the  sclerosis  of  age. 
Cataract  cannot  positively  be  said  to  exist  unless  examina- 
tion with  artificial  light,  in  the  manner  to  be  described, 
reveals  distinct  opacities  in  the  substance  of  the  lens. 

Finally,  the  appearances  in  the  deepest  portion  of  the 
eye,  the  vitreous  body,  are  noted  in  the  examination  by 
daylight.  Every  shade  of  yellow,  red,  brown,  gray,  or 
blue  may  be  seen  reflected  in  its  substance.  These  re- 
flections are  often  of  grave  significance,  as,  for  example,  in 
the  condition  shown  in  Plate  38,0,  where  they  indicate  the 
presence  of  a  very  malignant  tumor  on  the  retina.  Similar 
clinical  appearances  may  be  due  to  inflammatory  exudates 
in  the  vitreous  body  or  to  severe  hemorrhages,  in  which 
case  the  color  of  the  blood  is  more  or  less  pronounced. 

So  much  for  the  examination  of  the  eye  by  daylight. 
We  may  conclude  it  by  testing  the 

2.  Tension  of  the  Eyeball. 

The  degree  of  intraocular  pressure  is  tested  with  the 
finger-tips,  just  as  we  test  the  consistency  or  fluctuation 
of  a  tumor.  The  patient  is  told  to  look  straight  before 
him  or  very  slightly  downward,  so  that  the  tip<  of  the 
two  index-fingers  can  be  placed  close  together  on  the 
upper  lid,  over  the  region  between  the  upper  margin  of 
the  cornea  and  the  equator  of  the  eyeball.  Gentle  press- 
ure is  exerted  alternately  with  each  finger,  the  other  pre- 
venting the  globe  from  rolling  or  moving  to  one  side. 
The  arms  should  be  held  in   an  easy  and   perfectly  sym- 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         37 

metrical  position,  so  that  the  muscular  tension  is  the  same 
in  both  arms,  and  to  do  this  the  operator  must  stand  in 
front  of  the  patient,  not  to  one  side.  For  similar  reasons 
it  is  better  to  use  the  two  index-fingers,  instead  of  the 
index  and  middle  fingers  of  the  same  hand. 

The  patient  must  be  careful  to  avoid  extreme  down- 
ward rotation  of  the  eyeball,  as  it  might  have  the  effect 
of  raising  the  tension  by  increasing  the  pressure  of  the 
external  eye-muscles.  In  rotating  the  globe  downward 
the  inferior  rectus  and  superior  oblique  exert  a  direct 
pressure  upon  it,  and  the  elevators  (superior  rectus  and 
inferior  oblique)  do  likewise,  because  they  are  put  on  the 
stretch  and  thereby  brought  into  close  contact  with  the 
eye.  Slight  as  it  is,  this  increase  in  the  tension  is  enough 
to  affect  the  accuracy  of  the  test. 

It  is  not  possible  to  obtain  trustworthy  results  in 
patients  who  during  the  examination  tightly  close  the 
lids,  especially  in  screaming  children.  By  persuasive  and 
careful  examination  it  is  usually  possible  to  accomplish 
the  end  in  the  case  of  an  adult,  even  when  the  eyeball  is 
sensitive  to  the  touch.  With  children  it  is  different,  and 
in  cases  of  suspected  increased  intraocular  tension  narcosis 
may  be  needed  before  the  examination  is  satisfactory. 

The  beginner  will  do  well  to  practise  this  important 
part  of  the  examination  as  much  as  possible  on  normal 
eyes,  so  as  to  become  thoroughly  familiar  with  the  resist- 
ance of  a  normal  eyeball. 

This  method  of  estimating  intraocular  tension  with  the  fingers  is,  of 
course,  not  very  accurate,  depending,  as  it  necessarily  does,  on  the  sub- 
jective feeling  of  the  surgeon,  which  is  lai'gely  a  matter  of  experience. 
When  the  tension  is  excessively  high  or  excessively  low  there  can,  of 
course,  be  no  doubt  that  the  eye  is  abnormal ;  but  slight  departures  from 
the  normal  are  not  always  so  easy  of  detection,  especially  as  there  are 
individual  variations  within  physiologic  limits.  Tbus  the  eyes  in  youth 
are  usually  less  resistant  to  the  touch  than  in  old  age,  when  the  sclera 
has  become  rigid.  Here  again  "practice  makes  perfect,"  and  the  ex- 
perienced can,  as  a  rule,  dispense  with  the  instruments  that  have  been 
devised  to  measure  intraocular  tension,  except  in  very  unusual  cases. 
These  instruments,  called  tonometers,  have  their  fallacies  ;  some  are  very 
complicated  and  it  is  not  always  convenient  to  use  them.  The  most 
serviceable,  as  far  as  my  experience  goes,  are  those  designed  by  A.  Fick 
and  Maklakow,  both  of  which  yield  fairly  accurate  results  if  properly 


38  EXTERNAL  DISEASES  OF  THE  EYE. 

handled.     To  obtain  accurate  results  with  Pick's  tonometer  an  assistant 
is  needed,  and  great  care  is  necessary.    Maklakow's  method  is  easier  and 

simpler. 

The  ideal  way  to  express  the  tension  would  be  by  the 
number  of  millimeters  in  a  column  of  mercury  correspond- 
ing to  the  intraocular  pressure  in  each  case.  Instead, 
however,  as  the  tension  is  tested  with  the  finger-tips,  we 
designate  increased  resistance  by  T  +  l,  T  +  2,  T  —  3,  and 
decreased  resistance  by  T  —  1,  T  —  2,  T  — 3,  where  T  +  3 
denotes  that  the  finger  is  unable  to  produce  any  appreciable 
depression  in  the  eyeball,  and  T — 3,  that  the  finger  feels 
no  resistance  whatever — the  globe  is  "as  soft  as  mush." 

The  examination  is  now  continued  either  by  artificial 
light  or  the  examiner  proceeds  to  the  functional  testing 
of  the  eye.  The  choice  will  depend  on  whether  the  em- 
ployment of  the  latter  is  necessary,  or  even  possible.  li\ 
on  account  of  spasm  in  the  lids,  tears,  violent  pain,  or 
serious  injury,  it  is  impossible  to  test  the  acuteness  of 
vision,  it  must,  of  course,  be  postponed.  In  medicolegal 
cases,  however,  it  is  advisable  to  test  the  vision  of  each 
eye  if  it  is  at  all  possible.  Holders  of  accident-insurance 
policies  do  not,  as  a  rule,  malinger  at  the  first  examina- 
tion, though  they  may  do  so  later  on,  and  it  is  often  very 
useful  (in  such  cases)  to  know  in  time  the  acuteness  of 
vision  of  the  uninjured  eye. 

The  functional  test  is  also  called  the  subjective  examina- 
tion, as  distinguished  from  the  objective,  with  which  we 
have  been  dealing  so  far,  because  the  examiner  relies  on 
the  data  obtained  from  the  patient.  If  it  is  decided  to 
apply  this  test,  the  first  step  consists  in 


3.  Testing  Acuteness  of  Vision. 

The  test  is  first  applied  to  each  eye  separately  ;  later,  to 
both  at  once. 

It  is  well  to  form  the  habit  of  examining  the  right  eye 
first,  and  to  preserve  the  same  order  in  writing  the  history, 
as  it  makes  it  easier  to  understand  at  any  future  reading. 


Examination  of  the  eve  in  disease.      39 

As  the  acuteness  of  vision  is  usually  tested  for  the  purpose 
of  correcting  errors  of  refraction,  myopia,  hypermetropia, 
or  astigmatism,  a  set  of  lenses  should  be  at  hand. 

The  first  requisite  is  a  good  light,  to  insure  sufficient 
illumination  of  the  signs — usually  letters — by  the  reading 
of  which  the  acuteness  of  vision  is  determined.  The 
type-card  is  therefore  hung  in  a  strong  light  opposite,  or 
next  to  a  window.  If  the  examiner  is  able  to  discern 
with  ease  the  letters  which  correspond  to  his  own  visual 
power  the  light  is  sufficiently  strong.  This  control-test 
should  never  be  omitted,  as  any  diminution  of  the  light 
affects  the  visual  acuity  unfavorably.  As  Schweigger 
aptly  says,  the  improvement  in  a  patient's  eyesight  which 
we  observe  at  successive  examinations  is  very  often  an 
improvement  in  the  weather  rather  than  in  the  disease. 
If,  therefore,  the  daylight  is  not  strong  enough  to  illumi- 
nate the  type-card  properly,  artificial  light  must  be  used. 
The  source  of  light  may  be  the  same  as  that  used  for  the 
ophthalmoscopic  examination  later  on,  care  being  taken  to 
protect  the  patient's  eyes  with  a  shade,  so  that  the  light 
falls  only  on  the  type-card. 

A  transparent  type-card  may  also  be  employed  to  insure 
a  good  illumination  of  the  test-letters.  The  card  is  fastened 
to  the  window  and  a  mirror  is  placed  opposite  at  the 
proper  distance,  the  patient  reading  the  letters  as  they  are 
reflected  in  the  mirror.  This  arrangement  has  the  ad- 
vantage of  enabling  the  examiner  to  stand  near  the  patient 
and  the  type-card  at  the  same  time,  so  as  to  point  to  the 
letters  he  is  to  read.  In  a  small  room  the  necessary  dis- 
tance from  patient  to  type-card  can  best  be  obtained  by 
this  device. 

The  test  for  acuteness  of  vision  is  based  on  the  follow- 
ing considerations  :  Suppose  we  were  to  test  the  vision  by 
the  simplest  possible  means,  by  asking  the  patient  to  tell, 
for  instance,  how  many  fingers  we  had  stretched  out  on 
the  background  of  our  black  coat.  A  normal  eye  would 
be  able  to  distinguish  such  large  objects  at  a  great  distance ; 
in  fact,  we  should  have  to  move  away  50  meters  before  the 


40  EXTERNAL   DISEASES  OF  THE  EYE. 

fingers  would  appear  indistinct.  This  would  be  the  limit ; 
at  a  greater  distance  than  50  meters  a  person  with  normal 
eyes  could  no  longer  recognize  the  fingers  with  certainty. 
Xow,  if  another  person  were  unable  to  count  the  same  fin- 
gers when  placed  more  than  25  meters  away,  that  person 
would  possess  only  half  the  visual  power,  or  Jfj-,  because 
the  object  to  be  perceived  by  him  would  have  to  be  brought 
nearer  by  one-half  the  distance.  If  the  distance  had  to  be 
reduced  to  10  meters,  to  enable  a  person  to  count  the 
fingers,  his  vision  would  evidently  be  ecpial  to  one-fifth 
the  normal,  or  i§ ;  and  at  5  meters  the  visual  acuity 
would  be  y1^-,  or  -^.  The  acuteness  of  vision  can  therefore 
be  expressed  by  a  fraction  in  which  the  numerator  indicates 
the  greatest  distance  at  which  the  person  examined  is  able 
to  recognize  an  object,  and  the  denominator  the  e/reedest  dis- 
tance at  which  a  normal  eye  can  recognize  the  same  object — 
in  other  words,  the  normal  distance  for  that  object.  For 
the  outstretched  fingers  this  distance  is  50  meters.  Nor- 
mal vision  is  therefore  represented  by  |~J,  or  1  ;  abnormal 
vision,  by  some  fraction  of  1. 

Now,  if  we  were  actually  to  adopt  this  plan  of  testing 
the  acuteness  of  vision  we  should  find  this  running  back- 
ward and  forward  with  outstretched  fingers  over  a  distance 
of  50  meters  rather  troublesome.  Therefore,  instead  of 
varying  the  distance  from  the  patient  to  the  object,  we 
vary  the  size  of  the  object.  We  use  test-objects  of  vary- 
ing normal  distances.  Suppose,  for  instance,  we  choose  5 
meters  once  for  all  as  the  distance  for  applying  the  test; 
it  is  evident  that  an  object  10  times  smaller  than  the 
outstretched  fingers  will  have  to  be  used  as  the  standard. 
Such  an  object  would  be,  for  instance,  a  letter  7.5  mm.  in 
height.  Letters  of  this  size  can  just  be  discerned  by  a 
normal  eye  at  a  distance  of  5  meters;  their  normal  dis- 
tance, therefore,  is  5  meters  ;  and  we  place  the  number  5 
over  a  row  of  letters  of  this  size  which  form  the  lowest 
line  on  the  type-card. 

In  the  next  line  above,  the  letters  arc  twice  as  large  ;  a 
normal  eye  should  therefore  be  able  to  read  them  at  twice 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         41 

the  distance,  or  10  meters.  This  row  of  letters  is  desig- 
nated by  the  number  10,  which  is  their  normal  distance. 
If  no  smaller  letters  than  these  can  be  discerned,  vision  is 
^,  or,  keeping  the  same  fraction,  fa. 

The  letters  in  the  third  row  are  three  times  as  large  as 
those  in  the  first  row  (which  are  7.5  mm.  high) ;  a  normal 
eve  should  therefore  be  able  to  read  them  at  three  times 
the  distance,  or  15  meters.  This  row  is  marked  15,  its 
normal  distance.  If  an  individual  cannot  read  any  let- 
ters smaller  than  these,  his  vision  is  evidently  ^,  or,  keep- 
ing the  same  fraction,  fa. 

The  letters  in  the  fourth  row  are  four  times  as  large 
as  those  in  the  first  row,  and  are  designated  by  their 
normal  distance,  20  meters.  If  these  letters,  which  a 
normal  eye  can  read  at  four  times  the  distance,  or  20 
meters,  are  the  smallest  that  can  be  discerned,  vision  is 
evidently  ^,  or  fa. 

The  letters  in  the  fifth  row  are  six  times  as  large  as 
those  in  the  first  row,  and  above  them  is  a  single  large 
letter,  ten  times  as  large  as  the  first,  which  correspond 
respectively  to  visions  of  -^  (or  fa)  and  fa  (or  -fa).  The 
normal  distance  at  which  the  sixth  row  should  be  read  is 
6x5,  or  30,  and  it  is  accordingly  marked  30;  similarly, 
the  large,  single  letter  at  the  top  is  marked  50.  The  large- 
letter  test  is  equivalent  to  the  finger-test. 

Now  we  can  measure  visual  acuities  ranging  from  fa 
(or  J)  to  fa  (or  fa)  without  changing  the  position  of  the 
type-card,  which  remains  fixed  at  a  distance  of  5  meters. 
Or,  the  type-card  may  be  fixed  at  'a  distance  of  10  meters, 
in  which  case  the  readings  would  be  t$=1,  ijj~~§?  JJ= J, 
J$=J,  according  to  the  letters  the  patient  is  able  to  read. 

It  appears  therefore  that  the  numerator  in  the  fraction 
corresponds  to  the  distance  in  meters  of  the  patient  from  the 
type-card,  and  the  denominator  corresponds  to  the  distance 
at  which  the  type  should  be  read  normally.  Example :  The 
distance  of  the  patient  from  the  card  is  5  meters;  if  the 
type  marked  15  is  discerned  the  vision  is  fa,  or  ^. 

A  simpler  way  of  stating  the  rule  is :  Above  the  line 


42  EXTERNAL    DISEASES  OF  THE  EYE. 

put  the  distance  that  suits  the  patient  ;  below  the  line,  the 

distance   that    Suits   the    norm"/   eye. 

In  the  example  given  above,  the  patient  reads  the  type 
which  a  normal  eye  discerns  at  15  meters,  at  no  greater 
distance  than  5  meters — that  is,  at  a  distance  equal  to  ^ 
the  normal  distance  ;  hence  his  visual  acuity  is  only  \. 

This  extremely  practical  system  of  testing  the  acuteness 
of  vision  we  owe  to  Snellen,  and  his  type-cards,  which  we 
have  just  described  (and  which  can  he  bought  in  any 
bookstore),  are  now  universally  used  ;  at  least  his  system 
is  always  followed,  whether  his  own  type-cards  or  others 
constructed  on  the  same  principle  by  other  authors  be 
used.  Some  type-cards  are  designed  for  even  smaller 
fractions,  or  decimals  are  substituted  for  common  frac- 
tion-, etc. 

When  a  transparent  type-card  is  used  it  is  placed  beside 
the  patient,  and  the  mirror  ö  meters  away  ;  the  row  of 
letters  marked  10  therefore  represents  the  normal  type, 
and  the  numerator  is  10,  instead  of  5,  since  the  letters  are 
actually  10  meters  distant  from  the  patient. 

For  children  and  illiterate  persons  forh-like  figures, 
E  Id  Fl,  in  various  positions,  of  the  same  size  as  the 
letters,  are  used.  These  figures  possess  the  additional 
advantage  of  being  uniform  in  shape,  whereas  some  letters, 
as  VOL,  are  easier  to  read  than  others,  like  B  R  Z  N 
On  the  other  hand,  this  quality  of  not  being  equally  legi- 
ble is  useful  in  the  examination  of  malingerers.  For  if 
a  patient  reads  all  the  letters  in  one  row  easily  and  with- 
out hesitation,  he  is  always  able  to  discern  one  or  more  of 
the  easier  ones  in  the  next  row  also  ;  and  if  he  fails  to  do 
this,  malingering,  or  at  least  exaggeration  of  his  condition. 
may  be  suspected.  As  ;i  control-test,  the  vision  is  tried 
at  various  distances.  If  the  answers  are  given  honestly 
the  result  will  always  be  approximately  the  same;  for  in- 
stance, ,;;-,  ,'-',.  -,.  when  the  test  is  made  at  the  distances  of 
3,  2.  and  1  meter  respectively.  The  malingerer,  on  the 
other  hand,  is  apt  to  claim  better,  or  at  least  the  same, 
visual  acuteness  as  the  type-card  is  brought  nearer;  hence 


EXAMINATION  OF  THE  EYE  IN  DISEASE.        43 

a  suspected  malingerer  should  always  be  tested  at  various 
distances. 

The  same  plan  may  be  adopted  if  the  patient  fails  to 
read  even  the  largest  letter,  although  it  is  better  in  such  a 
case  to  ask  him  to  count  the  outstretched  fingers,  the 
result  being  recorded  as  "  Counts  fingers  at  0.2,  or  2,  or  4 
meters,"  etc.  If  he  is  unable  to  count  fingers,  we  try  if  lie 
can  see  movements  of  the  hand  at  0.2,  0.5  meter,  etc.,  and 
record  :  "  Perceives  movement  of  the  hand  at  . 
meters." 

When  even  this  power  no  longer  exists,  the  perception 
of  light  should  be  tested  in  a  dark  room,  by  alternately 
covering  and  uncovering  a  lamp  or  candle,  noting  the  dis- 
tance at  which  the  light  is  perceived.  It  is  only  when 
(qualitative)  light-perception  is  absent  that  we  speak  of 
blindness  or  amaurosis. 

In  testing  the  accommodation  for  the  purpose  of  select- 
ing glasses,  etc.,  consecutive  texts  in  varying  sizes  of  type 
are  substituted  for  the  letters.  The  type-cards  (after 
Snellen)  are  provided  with  these  text^,  which  arc  compiled 
on  the  same  principle  as  the  letters. 


The  foregoing  description  lias  been  made  as  easy  as  possible,  and  differs 
somewhat  from  that  usually  given,  which  reads  simply:  Acuteness  of 
vision  is  determined  by  finding  the  smallest  subtended  angle  in  which 
the  eye  can  recognize  the  shape  of  a  given  object.  For  objects  at  the 
same  distance  this  angle  is  assumed  proportional  to  the  size  of  the  object, 
which  is  sufficiently  accurate  for  small  angles.  For  larger  angles  the  size 
of  the  object  must  be  taken  as  equal  to  twice  the  tangent  of  half  the  angle. 
Hence  the  respective  letters  on  the  type-card  are  not  exactly  3,  or  5,  or 
10  times  as  large  as  the  letters  which  are  7.5  mm.  long,  but  only  approxi- 
mately. In  order  to  express  the  visual  angle  in  commensurable  terms  a 
conventional  unit  has  been  selected.  For  this  purpose  an  angle  of  5' 
(minutes)  is  taken  for  the  recognition  of  letters  the  thichiess  of  which  is 

one-fifth  the  height.     In  the  formula  V  =^n,  d  stands  for  the  distance  at 

which  the  letter  can  be  distinctly  recognized;  D,  for  the  distance  at 
which  the  letter  subtends  an  angle  of  5'  (minutes);  and  V,  the  visual 
acuity. 

The  angle  5'  is  arbitrary ;  it  corresponds  to  the  average  normal  vision. 
Many  persons  see  quite  clearly  at  a  smaller  visual  angle  ;  thus,  the  letters 
numbered  5  may  be  discerned  at  a  distance  of  7.5,  or  even  10  meters. 
Such  persons  would  possess  a  vision  equal  to  l£  and  double  the  normal 
respectively. 


44  EXTERNAL  DISEASES  OF  THE  EYE. 

It  is  important  to  observe  the  following  precaution  in 
testing  the  aeuteness  of  vision.  When,  in  the  examina- 
tion of  the  right  eye,  for  instance,  the  left  eve  is  to  be  ex- 
cluded from  the  visual  field,  it  must  not  be  covered  with 
the  hand  or  fingers,  except  possibly  with  the  hollow  of  the 
hand,  so  that  the  eye  can  remain  open.  It  is  better  to  use 
a  pair  of  testing-spectacles  in  which  the  left  lens  is  re- 
placed by  a  disk  of  tin  or  pasteboard,  which  cuts  off  the 
view  without  closing  the  eye.  Pressure  on  the  eye  with 
the  hand  or  finger,  even  for  a  short  time,  disturbs  vision 
by  altering  the  normal  outline  of  the  cornea,  so  that  the 
aeuteness  of  vision  obtained  is  incorrect.  Any  one  can 
convince  himself  of  the  truth  of  this  statement  by  press- 
ing upon  his  eye  for  a  short  time. 

Now,  suppose  the  right  eye,  for  example,  is  to  be  tested. 
We  first  note  the  visual  acuity  without  glasses — in  other 
words,  the  uncorrected  vision.  If  this  is  found  to  be  less 
than  1,  the  effect  of  concave  or  convex  lenses  of  varying 
strengths  is  tried.  The  weakest  concave  or  strongest 
convex  lens  that  produces  the  best  vision  indicates  the 
degree  of  subjective  myopia  or  apparent  hypermetropia. 
If  spherical  glasses  fail  to  bring  the  vision  up  to  1, 
cylindrical  glasses  must  be  tried.  Cylindrical  lenses, 
plus  or  minus  1  (or  even  other  cylindrical  lenses),  are 
held  in  front  of  the  eye,  in  a  horizontal,  vertical,  or  either 
of  the  two  oblique  directions,  to  see  whether  a  combina- 
tion of  spherical  and  cylindrical  lenses,  or  cylindrical 
lenses  alone,  produce  the  best  vision.  The  direction  of 
the  axis  of  the  cylinder  is  best  recorded  as  follows  :  Axis 
vertical,  or  A.  v.  or,  simply,  ||  ;  Axis  horizontal,  or  A.  h. 
or  =  ;  axis  x  degrees  temporal  or  nasal  above — L  c,  the 
upper  end  of  the  axis  deviates  x  degrees  from  the  perpen- 
dicular to  the  temporal  or  nasal  side. 

The  notes  of  the  test  for  visual  acuity  would  then  read 
something  like  this  : 

r.  ^  _1>5  gph.  _$_  0  cy]t  _o.7o  ||  V  =  1. 
L.  -$T).     No  improvement  with  glasses. 


.- 


EXAMINATION  OF   THE  EYE  IN   DISEASE.         45 

[Ordinarily,  in  this  country,  this  record  would  be  as 
follows  :  R.  E.  V=^j-  without  correction  ;  with  —  1.5  D 
sph.,  o  —  0.75  D  cyl.,  axis  90°  V  =  f  or  1 .  L.  E.  V 
=  -fo  ;  no  improvement  with  glasses. — Ed.] 

In  this  patient's  left  eye  we  may  have  noticed  a  central 
corneal  opacity,  which  explains  the  low  visual  acuity  of 
y1^ ;  or  we  may  find,  in  another  case,  upon  continuing  the 
examination,  that  the  amblyopia  is  caused  by  disease  in 
the  fundus. 

In  the  above  record  of  the  right  eye  (R.)  the  uncorrected 
vision  is  ^  ;  with  a  spherical  lens  the  visual  power  is  raised 
to  y?  an(l  finally  the  effect  of  the  cylindrical  lens  is  to 
bring  the  vision  up  to   1. 

Ophthalmologists  have  their  own  system  of  numberin 
spectacle-lenses.  Ordinarily  a  lens  is  designated  by  it 
focal  length  ;  but  spectacle-lenses  are  numbered  according 
to  their  refractive  power.  A  lens  of  1  meter  focus  is 
taken  as  the  unit,  and,  with  the  exception  of  lenses  0.5 
and  0.75,  all  others  are  multiples  of  the  meter-lens,  or 
diopter,  as  it  is  also  called.  A  lens  of  2  D  therefore  has 
a  refractive  power  twice  as  great  as  a  lens  of  1  I),  and 
consequently  half  the  focal  length,  or  0.5  meter  ;  a  lens  of 
3  D  has  three  times  the  refractive  power  and  one-third 
the  focal  length  of  a  lens  of  1  D  (meter-lens  or  ml), 
etc.,  for  the  refractive  power  of  a  lens  is  the  inverse  of  its 
focal  length.  The  smaller  the  focal  length  the  greater  the 
refractive  power. 

To  find  the  focal  length  of  a  lens  in  the  dioptric  system 
divide  100  bv  the  number  of  diopters.  Thus,  the  focal 
length  of  a  lens  of  3  D  is  y$  =33.3  cm.;  that  of  a  lens 
of  8  D,  12.5  cm.  To  find  the  number  of  diopters  for  a 
given  focal  length — 10  cm.,  for  example — divide  100  by 
the  number  of  cm.  in  the  focal  length  :  Xffl  —  10  I)  ;  for 
20  cm.  the  number  of  diopters  is  5,  etc. 

In  the  old  system  a  lens  of  1  inch  focus  was  the  unit, 
and  all  the  lenses  in  use  were  fractions  of  this  unit.  No. 
\  had  a  focal  distance  of  2  inches ;  No.  J,  a  focal  distance 
of  3  inches,  etc.     The  number  of  the  lens  gave  the  focal 


46  EXTERNAL   DISEASES  OF  THE  EYE. 

distance  (more  correctly,  the  radius  of  curvature)  and  the 
refractive  power  at  the  same  time,  and  consequently  took 
the  form  of  a  fraction.  The  diopter  (Ml)  corresponds  to 
lens  fa  in  the  old  system.  To  change  from  the  new  sys- 
tem to  the  old,  divide  the  number  40  by  the  number  of 
diopters  ;  to  change  from  the  old  system  to  the  new,  divide 
the  same  number  (40)  by  the  denominator  of  the  fraction. 
For  example,  a  lens  of  2  D,  new  system,  is  No.  fa  in  the 
old  ;  lens  No.  ^,  old  system,  corresponds  to  a  lens  of  5  D 
in  the  new  system.  The  lenses  in  the  two  systems  are 
practically  the  same,  the  nomenclature  only  being  different. 

The  refractive  power  of  the  eye,  as  determined  with 
spectacle-lenses  by  the  so-called  subjective  test,  is  not 
always  quite  accurate,  because  accommodation  conies  into 
play,  whereby  myopia  may  be  exaggerated  or  hyper- 
metropia  diminished.  Absolutely  correct  results  can  be 
obtained  only  by  objective  examination  with  the  ophthal- 
moscope, or  by  the  Schmidt-Rirrvpler  method,  or  with  the 
shadow-test.1 

After  the  acutcness  of  vision  has  been  ascertained  the 
examination  is  continued  by  artificial  light  in  a  dark 
room,  the  first  step  being 

4.  Examination  with  Lateral  Illumination. 

This  part  of  the  examination  is  important  on  account 
of  the  information  it  affords  as  to  the  condition  of  the  ante- 
rior segment  of  the  eyeball,  which  cannot  be  obtained  at 
all,  or  but  imperfectly,  in  any  other  way,  especially  if  a 
good  corneal  loupe  is  employed. 

The  lamp  is  placed  on  a  table  to  the  right  and  a  little  in 
front  of  the  surgeon,  who  sits  facing  the  patient.  With  a 
convex  lens  of  15-20  D,  which  is  found  in  the  ophthal- 
moscope-case, the  light  is  thrown  into  the  eye  under  ob- 
servation so  as. to  focus  on  the  parts  which  it  is  desired  to 
examine  with    special  care.     The  rays  collected    by  the 

1  For  a  full  description  of  the  objective  methods  of  testing  the  refract- 
ing power  of  the  eye,  see  the  author's  Grundriss  und  Atlas  der  Ophthal- 
moskopie. 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         47 

lens  form  a  small  brilliant  image  of  the  flame  of  the  lamp 
at  this  point.  The  parts  of  the  cornea,  iris,  etc.,  illumi- 
nated in  this  way  are  thus  brought  into  a  bright  light  and 
stand  out  in  strong  relief  against  the  dark  background  of 
their  surroundings.  Suppose,  for  example,  the  iris  to  be 
discolored,  so  that  a  gray  opacity  in  the  overlying  cornea 
cannot  be  seen ;  if  only  the  cornea  is  illuminated,  the  iris, 
being  in  shadow,  forms  a  good  background  for  the  opacities 
in  the  cornea  and  they  at  once  become  visible.  Or,  if  the 
cornea  is  left  in  shadow  and  the  iris  only  illuminated,  any 
changes  in  the  latter  and  in  the  pupil  can  be  seen.  The 
most  minute  alterations  in  the  cornea,  iris,  and  crystalline 
lens,  which  would  escape  detection  in  the  strongest  day- 
light, can  be  discerned  by  this  method. 

To  obtain  the  best  results  with  lateral  illumination  a 
loupe  is  necessary.  HadnaeWs  spherical  loupe  is  the 
best,  as  it  covers  a  fairly  large  field.  The  loupe  is  held  in 
the  left  hand,  the  right  manipulating  the  illuminating- 
lens.  The  proper  cooperation  of  the  two  lenses,  on  which 
the  success  of  the  method  largely  depends,  is  no  easy 
matter  to  accomplish  and  requires  a  great  deal  of  practice. 
Among  other  things,  this  method  enables  us  to  locate 
accurately  certain  minute  depositions  on  the  posterior 
surface  of  the  cornea  which  occur  in  iritis  and  in  cyclitis, 
and  which  cannot  be  detected  in  any  other  way.  Similar 
small  gray  dots  occur  in  the  crystalline  lens  ;  but  they  can 
readily  be  distinguished  from  the  former  with  the  aid  of 
a  loupe.  For  when  the  depositions  on  the  cornea  are 
clear  and  distinct,  the  crystalline  lens  must  be  out  of  focus  ; 
and,  on  the  other  hand,  to  make  a  close  examination  of 
the  lens  the  loupe  must  be  held  nearer  the  eye,  whereupon 
the  cornea  necessarily  disappears  from  the  field.  (Hence, 
if  depositions  on  the  cornea  and  grayish  dots  in  the  pupil 
are  present  at  the  same  time,  we  can  study  the  two  condi- 
tions separately,  which  may  be  of  great  value.)  If  even 
by  using  the  loupe  the  surgeon  finds  it  difficult  to  see  the 
depositions  on  the  cornea,  let  him  move  his  head  to  and 
fro  (after  he  has  focussed  the  cornea  with  a  strong  light 


is  EXTERNAL    DISEASES   OF   THE   EVE. 

shining  on  it),  and  the  spots  will  be  seen  to  follow  the 
motions  of  the  head  and  become  perfectly  distinct.  Some- 
times it  is  difficult  to  distinguish  the  depositions  from 
minute  dots  on  the  anterior  surface  <>f  the  cornea.  In 
that  ease  a  few  particles  of  calomel  are  applied  to  the 
cornea  with  a  camel's-hair  brush.  The  patient  will  not 
be  inconvenienced  if  only  a  very  little  calomel  is  applied, 
which  can  be  accomplished  by  tapping  the  brush  with  the 
finger  after  it  has  been  dipped  in  the  calomel.  Now  the 
dots  on  the  anterior  surface  of  the  cornea  can  easily  be 
-«■en  distinct  from  those  on  the  posterior  surface,  especially 
if  the  surgeon  moves  his  head  from  side  to  side  as  before, 
or  the  particles  of  calomel  are  put  in  motion  by  the  act  of 
winking. 

If  the  pupil  can  be  dilated,  it  is  possible  with  lateral 
illumination  to  look  into  the  vitreous  body.  The  light 
must  enter  the  eye  as  nearly  as  possible  in  perpendicular 
lines,  and  the  surgeon,  standing  close  to  the  lamp,  directs 
his  gaze  along  the  entering  beam  of  light.  In  this  way 
foreign  bodies,  hemorrhages,  neoplasms,  and  detachments 
of  the  retina  in  the  anterior  portion  of  the  vitreous  can  be 
detected  and  their  color  studied. 

The  next  procedure  is  the 

5.  Examination  by  Transmitted  Light. 

This  important  part  of  the  examination  serves  to  con- 
firm and  show  even  more  clearly  some  of  the  results  ob- 
tained by  lateral  illumination.  It  also  reveals  the  faintest 
reaction  of  the  pupil  to  light.  For  the  rest,  its  chief 
object  is  to  detect  opacities  in  the  refracting  media,  the 
cornea,  lens,  and   vitreous  body. 

The  lamp  being  placed  a  little  behind  and  to  one  side 
of  the  patient,  the  surgeon  throws  the  reflection  of  the 
lamp  into  the  eye  by  means  of  the  ophthalmoscope,  illu- 
minating the  pupil  so  that  it  appears  bright  red  against 
the  dark  background  of  the  eye,  which  is  in  shadow. 
The   pupil   contracts  as  soon  as  the   light  strikes  it,  unless 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         49 

there  is  pupillary  paralysis  from  any  cause.  By  noting 
the  character  of  the  beam  of  light  as  it  emerges  from  the 
pupil,  after  being  reflected  from  the  fundus,  we  can  detect 
any  opacities  there  may  be  in  the  pupillary  area,  manifest- 
ing themselves  as  more  or  less  intense  shadows  which 
intercept  the  light — especially  if  they  are  located  in  the 
cornea,  lens,  or  vitreous  body.  Opacities  due  to  cataract 
are  brought  out  very  distinctly  in  this  way  (see  Plate 
33,  b,  c),  particularly  the  fainter  opacities  of  lamellar 
cataract,  which  often  occur  in  a  rudimentary  form  only. 
Opacities  in  the  anterior  or  posterior  poles  of  the  crystal- 
line lens  can  also  be  seen,  whether  the  nucleus  be  clear  or 
opaque.  If  the  patient,  while  the  pupil-area  is  steadily 
illuminated,  is  directed  to  look  up  or  to  one  side,  an 
opacity  in  the  anterior  pole  will  move  with  the  pupil,  in 
the  center  of  which  it  remains  fixed.  An  opacity  in  the 
posterior  pole,  on  the  contrary,  remains  stationary,  and 
appears  to  move  downward  when  the  gaze  is  directed 
upward,  because  the  pupil  moves  upward  in  front  of  it. 
A  posterior  opacity  from  pigmentary  degeneration  of  the 
retina  can  be  distinctly  seen  only  by  transmitted  light.  It 
always  lies  close  to  the  corneal  reflex. 

To  study  minute  changes  in  the  cornea,  anterior  cham- 
ber, and  iris  a  strong  convex  lens  may  be  used  with  ad- 
vantage in  the  examination  by  transmitted  light.  The 
delicate  blood-vessels,  which  often  persist  for  some  time 
in  the  cornea  after  parenchymatous  keratitis,  are  best  seen 
with  a  "loupe-mirror;"  they  appear  as  fine,  dark  lines 
against  the  red  background  of  the  pupil,  which  has  pre- 
viously been  dilated,  if  possible.  Deposits  on  the  pos- 
terior layer  of  the  cornea  also  become  visible.  In  these 
examinations  a  strong  convex  lens,  such  as  is  used  under 
certain  circumstances  in  the  later  stages  of  ophthalmos- 
copic examination,  is  fixed  behind  the  sight-hole  of  the 
ophthalmoscope,  and  the  surgeon  approaches  so  close 
to  the  eye  under  examination  that  its  cornea  lies  within  the 
focal  distance  of  this  convex  lens.  The  lens  need  not  be 
very  powerful  (+6  or  +8  D),  or  a  lens  of  -f  15  I)  to 

4 


50  EXTERNAL  DISEASES  OF  THE  EYE. 

+  18  D  will  answer  if  the  ophthalmoscope  happens  to 
contain  such  a  one. 

[An  ophthalmoscope  should  always  be  provided  with  a 
+  16  or  +20  D  lens  in  its  series.  Examination  of  the 
transparent  media  with  such  a  lens  is  most  important, 
particularly  in  the  study  of  late  corneal  lesions. — Ed.] 

When  the  examination  by  means  of  transmitted  illu- 
mination has  been  completed,  and  not  till  then,  we  pro- 
ceed to  the  ophthalmoscopic  examination  proper,  begin- 
ning with 

6.  Examination  with  the  Inverted  Image, 

which  is  followed  by 

7.  Examination  with  the  Upright  Image. 

A  detailed  description  of  these  two  methods  is  found  in 
my  Grundris8  und  Atlas  der  Ophthalmoskopie,  to  which 
reference  has  been  made. 

This  ends  the  examination  for  most,  though  not  for  all, 
patients.  It  may  now  be  necessary,  for  instance,  to 
measure  the 

8.  Accommodation. 

In  practice,  accommodation  is  measured  by  finding  the 
nearest  point,  P  (punctum  proximum),  at  which  the  small- 
est readable  print  can  be  deciphered.  Each  eye  is  first 
tested  separately,  by  bringing  the  test-type  closer  and 
closer,  until  the  letters  become  blurred  and  illegible. 
This  shortest  reading-distance  is  then  measured  with  a 
rule,  the  zero-point  being  held  opposite  the  sclerocorneal 
junction.  When  the  accommodation  is  good,  as  in  young 
eyes,  and  the  test-card  can  be  held  very  close  to  the  eye,  a 
successively  smaller  type  must  be  used  as  the  distance  is 
diminished,  because  large  print  can  be  read  even  without 
proper  accommodation  in  "diffusion-circles."  The  small- 
est readable  type  should  therefore  be  selected  for  the  test. 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         51 

In  measuring  the  accommodation  the  refractive  power 
of  the  eye  must  be  accurately  known,  as  the  formula 

A  =  P  —  R 

is  used  in  the  calculation,  in  which  P  and  R  (punctum 
remotum)  are  expressed  in  diopters.  The  number  of 
diopters  for  P  is  found  by  taking  the  number  of  the  lens 
whose  focal  length  equals  the  distance  of  P  from  the 
cornea.  If,  for  example,  the  distance  from  the  near  point 
to  the  cornea  is  found  to  be  20  cm.,  P  is  expressed  by  5 
D,  the  number  of  the  lens  which  has  a  focal  length  of  20 
cm.  That  we  are  justified  in  expressing  the  distance  of 
the  near  point  from  the  cornea  by  the  number  of  a  lens 
appears  from  the  following  considerations  :  Suppose  the 
case  of  an  emmetropic  eye  having  no  power  of  accommo- 
dation. If  an  object  is  placed  20  cm.  distant  from  the 
cornea  no  distinct  image  will  be  formed  on  the  retina, 
since  the  rays  of  light  will  be  brought  to  a  focus  behind 
the  retina,  for  the  shorter  the  distance  of  an  object  from 
a  convex  lens  or  a  combination  of  two  convex  lenses  (such 
as  is  formed  in  the  eye  by  the  cornea  and  the  aqueous 
humor  and  crystalline  lens),  the  greater  the  distance  from 
the  lens  to  the  image  on  the  other  side.  In  order,  there- 
fore, to  obtain  a  distinct  retinal  image  of  an  object  20  cm. 
in  front  of  an  eye  incapable  of  accommodation,  the  rays 
of  light  coming  from  the  object  must  be  rendered  parallel, 
since  only  parallel  rays  entering  the  resting,  emmetropic 
eye  are  collected  on  the  retina.  This  would  be  accom- 
plished by  holding  a  lens  of  20  cm.  focal  length  close  in 
front  of  the  eye,  since  rays  coming  from  the  focal  point 
of  a  convex  lens  emerge  in  parallel  lines  on  the  other  side. 
A  distinct  image  of  the  object  would,  therefore,  be  formed 
on  the  retina  ;  and  the  eye  is  said  to  be  "  adjusted  "  or  ac- 
commodated for  such  an  object  by  a  lens  of  20  cm.  focal 
length.  In  other  words,  an  emmetropic  eye  is  accom- 
modated for  near  objects  by  a  lens  whose  focal  length  is 
equal  to  the  distance  of  the  object  from  the  eye,  the  lens 


52  EXTERNAL  DISEASES  OF  THE  EYE. 

being  assumed  tu  be  in  contact  with  the  cornea.  If  an 
eye  has  the  power  of  adjusting  itself  to  a  near  object  with- 
out the  aid  of  such  a  lens,  it  does  so  by  increasing  the 
refractive  power  of  its  crystalline  lens,  through  the  act 
called  accommodation,  by  an  amount  equal  to  the  refrac- 
tive power  of  the  artificial  lens  that  would  be  required. 

For  an  emmetropic  eye  the  number  of  the  lens  which 
expresses  P  at  the  same  time  gives  the  value  of  A.  For, 
since  the  distance  of  R  is  infinite,  R  —  OD;  hence,  in 
the  above  example,  A  =  5  D. 

In  myopic  and  hypermetropic  eyes,  on  the  other  hand, 
R  represents  a  certain  number  of  diopters,  corresponding 
to  the  degree  of  myopia  or  hypermetropia  present.  For 
ametropic  eyes,  therefore,  the  refractive  power  must  first 
be  ascertained  by  one  of  the  objective  methods  before  the 
accommodation  can  be  determined. 

For  myopic  eyes  the  number  of  diopters  which  express 
the  degree  of  myopia  must  be  subtracted  from  the  number 
of  diopters  which  correspond  to  the  distance  of  the  near 
point.  For  example  :  If  P  is  found  at  8  cm.,  —  12.5  D, 
and  myopia  =  3  D,  then  A  ~  9.5  D. 

For  hypermetropic  eyes,  on  the  other  hand,  the  number 
of  diopters  which  express  the  total  hypermetropia  is  added 
to  the  number  of  diopters  corresponding  to  P.  If,  there- 
fore, the  near  point  for  an  eye  of  4  D  hypermetropia  is 
found  at  10  cm.,  the  accommodation  is  14  D. 

The  exact  state  of  affairs  in  hypermetropia  is  as  follows  : 
In  facultative  hypermetropia,  in  which  R  is  virtually  behind 
and  P  in  front  of  the  eye,  the  formula  reads  :  A  =  P  — 
( — R)=  P  4"  R.  In  absolute  hypermetropia,  in  which 
both  P  and  R  lie  behind  the  eve — i.  e.s  both  are  nega- 
tive—the formula  reads  :  A  = —  P—  (—  R)  =  R  —  P; 
or,  in  other  words,  A  diminishes  the  hypermetropia  by  the 
amount  of  P. 

To  ascertain  whether  a  patient  has  normal  accom- 
modation,  it  is  needful  to  know  the  amplitude  of  accom- 
modation corresponding  to  his  age  ;  for  the  range  of 
accommodation  decreases  from  year  to  year,  because  the 


EXAMINATION  OF  THE  EYE  IN  DISEASE. 


53 


elasticity  of  the  lens  gradually  diminishes.     The  following 
table  supplies  this  information  : 


de  of 

the  Bange 

of 

Accommodation  fo 

r  the  Different 

Ages. 

Near  point 
(P.  p.)  in 
meters. 

Far  point  (P.  r.) 

Range  of  accommodation 

Age. 

in  meters. 

in  diopters. 

10.    . 

0.07 

c/> 

14 

15  .    . 

0.08 

— 

12 

20.    . 

0.1 

— 

10 

25  .    . 

0.12 

— 

8.5 

30  .    . 

0.14 

— 

7. 

35  .    . 

0.18 

— 

5.5 

40.    . 

0.22 

— 

4.5 

Pr. 

45  .    . 

0.28 

— 

3.5 

0.5 

50.    . 

0.4 

— 

2.5 

1.5 

55  .    . 

0.66 

-4 

(H. 

0.25) 

1.75 

2.5     (2.25) 

60  .    . 

•  2 

-2 

(H. 

0.5  ) 

1.0 

3.5     (3.0) 

65  .    . 

—4 

-1.3 

(H. 

0.75) 

0.5 

4.25    (3.5) 

70.    . 

—1 

-0.8 

(H. 

1.25) 

0.25 

5.0     (3.75) 

75  .    . 

—0.5 

-0.57 

(H. 

1.75) 

0 

5.75    (4.0) 
6.5      (4.0) 

0  .    . 

—0.4 

-0.4 

(H. 

2.5) 

0 

We  have  two  reasons  for  wishing  to  know  the  normal 
range  of  accommodation  :  First,  because  it  enables  us  to 
compute  the  loss  of  accommodation  in  disease ;  and, 
second,  because  when  the  physiologic  decrease  in  the  power 
of  accommodation  has  reached  a  certain  point  it  interferes 
with  the  power  of  seeing  near  objects,  a  condition  termed 
presbyopia.  As  age  advances  civilized  man  is  forced  to 
resort  to  the  use  of  convex  glasses.  As  long  as  vision  is 
distinct  at  a  distance  of  25-33  cm. — that  is,  so  long  as  A 
equals  4-3  D — no  appreciable  inconvenience  is  noticed  ; 
but  beyond  that  point  the  reading  of  fine  print  begins  to 
be  troublesome,  because  the  book  cannot  be  held  close  to 
the  eye.  Either  the  individual  chooses  larger  and  larger 
type  and  a  better  light,  or  gives  up  fine  needlework,  or 
the  aid  of  spectacles  is  invoked  to  supply  the  defective 
accommodation.  The  strength  of  the  glasses  must  be 
regulated  according  to  the  kind  of  work  for  which  they 
are  intended.     A  cobbler,  whose  working-distance  is  40 


54  EXTERNAL  DISEASES  OF  THE  EYE. 

cm.,  needs  only  half  as  strong  glasses  as  does  a  draughts- 
man who  works  at  a  range  of  20  cm. 

In  the  table  presbyopia  is  assumed  to  begin  when  the 
near  point  has  receded  to  a  distance  of  25  cm.  from  the 
cornea ;  or,  in  other  words,  when  A  begins  to  be  less  than 
4  D.  The  degree  of  presbyopia  and  the  number  of  the 
lens  necessary  to  correct  it  are  readily  found  by  subtract- 
ing the  existing  power  of  accommodation,  expressed  in 
diopters,  from  the  working-distance  desired.  Example  : 
Distance  desired,  33  cm.  (=  3  D) ;  existing  accommoda- 
tion, 2  D ;  number  of  spectacle-lens  required,  1  D. 

The  foregoing  applies  to  the  emmetropic  eye,  and  in 
this  connection  the  following  facts  must  be  borne  in  mind  : 
The  above  table  shows  that  hypermetropic  change  begins 
at  the  age  of  55,  on  account  of  the  lessened  refractive 
power  of  the  crystalline  lens.  This  tendency  of  the  em- 
metropic eye  to  become  hypermetropic  must  be  taken  into 
account  when  glasses  are  prescribed,  by  increasing  the 
strength  of  the  lenses  in  proportion  to  the  degree  of 
hypermetropia  present.  The  necessary  correction  is  in- 
dicated in  the  column  of  numbers  marked  Pr.  But  if 
cataract  is  present,  the  refractive  power  of  the  lens  is  at 
first  increased,  thereby  compensating  for  the  hypermetro- 
pia due  to  age.  For  such  cases  the  numbers  in  the  second 
column,  or  even  lower  ones,  must  be  used. 

For  eyes  that  were  originally  hypermetropic  the  spec- 
tacles prescribed  for  presbyopia  must,  of  course,  be  cor- 
rected for  the  degree  of  hypermetropia  normally  present ; 
while  for  myopic  eyes  the  degree  of  myopia  must  be  sub- 
tracted from  the  number  of  the  presbyopia-glasses.  Pres- 
byopia makes  itself  felt  later  in  short-sighted  persons  than 
in  those  who  possess  normal  vision.  [If  the  patient  is 
astigmatic  this  refractive  defect  must  be  properly  neu- 
tralized.— Ed.] 

In  measuring  normal  accommodation,  or  the  decrease  in 
accommodation  due  to  disease,  the  following  facts  are  to 
be  remembered  :  When  the  accommodation  is  very  slight, 
and  the  distance  of  the  near  point  correspondingly  great, 


EXAMINATION  OF  THE  EYE  TN  DISEASE.         55 

the  patient  is  unable  to  read  print  of  any  kind,  and  we 
have  to  produce  an  artificial  near  point  by  means  of 
convex  glasses.  If,  for  example,  it  is  found  that  the 
patient  can  read  fine  print  with  a  6  D  lens  at  a  distance 
of  10  cm.,  his  accommodation  is  equal  to  10  D  (the  num- 
ber of  diopters  which  are  equivalent  to  10  cm.)  less  the 
power  of  the  lens,  or  4  D.  If  the  patient  is  10  years 
old,  his  accommodation  ought  to  be  14  D,  and  he  there- 
fore lacks  10  D. 


9.  Measuring  the  Field  of  Vision. 

In  many  diseases  of  the  eye  and  in  a  number  of  ner- 
vous affections  it  is  necessary  to  measure  the  field  of 
vision.  Whereas  visual  acuity  depends  on  the  function- 
ating power  of  the  center  of  the  retina  only,  the  limits  of 
the  field  of  vision  are  determined  by  testing  the  percep- 
tive powers  of  the  entire  surface  of  the  retina,  and  par- 
ticularly of  its  peripheral  portions.  With  perfectly  good 
visual  acuity  there  may  coexist  gaps  in  the  field  of  vision, 
so-called  scotomata;  or  there  may  be  regular  or  irregular 
concentric  contractions — irregular  when  the  field  is  con- 
tracted more  in  one  part  than  in  others.  One-half  of  the 
visual  field  may  be  wanting,  usually  on  both  sides,  a  con- 
dition termed  hemianopsia;  or  there  may  be  so-called 
homonymous  defects,  dark  areas  of  the  same  size  and  shape 
occupying  symmetrical  portions  of  both  halves  of  the 
visual  field  (for  example,  absence  of  the  left  upper  quad- 
rant on  both  sides). 

The  limits  of  the  field  of  vision  can  be  roughly  ascer- 
tained by  very  simple  means,  and  it  is  better  always  to 
make  at  least  such  a  superficial  examination  rather  than 
omit  it  altogether  because  no  suitable  instrument  of  pre- 
cision happens  to  be  at  hand. 

The  simplest  way  is  the  following  :  The  patient,  either 
sitting  or  lying  down — for  the  examination  sometimes  has 
to  be  made  on  a  patient  in  bed — is  placed  opposite  the 
surgeon,  at  a  distance  of  about  0.5  meter,  so  that  the  faces 


56  EXTERNAL  DISEASES  OF  THE  EYE. 

of  the  two  are  in  parallel  planes.  The  patient  is  then 
required  to  fix  his  left  eye,  the  other  being  covered,  upon 
the  surgeon's  right  eye,  which  is  directly  opposite.  Keep- 
ing his  eve  steadily  fixed  on  the  patient's,  the  surgeon 
then  gradually  brings  his  outstretched  fingers  nearer  and 
nearer  to  the  line  joining  his  own  eye  and  the  patient's,  in 
a  plane  midway  between  them.  If,  for  instance,  the  right 
hand  is  extended  with  two  fingers  held  up,  the  fingers  can 
be  seen  and  counted  by  indirect  vision,  without  diverting 
the  gaze  from  the  patient's  face.  If  the  fingers  are 
gradually  brought  nearer  to  the  line  of  vision,  both  sur- 
geon and  patient  can  keep  them  in  sight,  supposing  both 
to  possess  a  normal  field  of  vision;  but  if  the  patient's 
field  of  vision  is  small,  or  much  restricted  on  the  temporal 
side,  he  will  not  be  able  to  see  the  fingers  until  they  are 
quite  near  the  connecting  line.  To  make  sure  that  the 
patient  really  sees  the  fingers,  the  surgeon  may  alternately 
move  them  and  hold  them  still  and  ask  the  patient  to  tell 
him  whether  they  have  moved  or  not.  In  this  way  the  sur- 
geon ascertains  how  far  the  visual  field  extends  in  all 
directions,  by  comparing  it  with  the  limits  of  his  own 
field,  although,  of  course,  the  result  cannot  be  set  down 
in  figures. 

In  many  cases  of  very  defective  vision  this  simple 
method  is  the  only  one  available,  as  the  patient  is  unable 
to  see  any  but  the  coarsest  test-objects. 

If  the  lens  is  blurred  by  cataract  the  flame  of  a  candle 
in  a  dark  room,  which  is  a  more  intense  stimulus  to  the 
retina,  must  be  used  for  a  test-object.  The  surgeon 
screens  the  light  with  his  hand  and  brings  it  successively 
into  the  different  regions  of  the  field,  and,  after  removing 
his  hand,  asks  the  patient  to  tell  which  direction  the  light 
comes  from.  This  projection-test,  as  it  is  called  in  contra- 
distinction to  the  ordinary  method,  may  also  be  performed 
with  the  ophthalmoscope  by  throwing  on  the  eye  to  be 
examined  the  reflection  of  the  lam])  from  various  direc- 
tions. It  forms  a  very  important  part  of  the  examination 
in  cataract,  as  it  reveals  any  pathologic  changes  in  the 


EXAMINATION  OF  THE  EYE  IN  DISEASE         57 

eye-ground  which  had  been  obscured  by  the  disease.  If, 
for  instance,  the  patient  fails  to  locate  the  light  promptly 
in  the  upper  segment  when  it  is  held  opposite  the  upper 
part  of  the  eye,  operation  for  cataract  is  not  advisable,  as 
there  are  probably  some  detachments  in  the  lower  portion 
of  the  retina. 

In  the  exact  measurement  of  the  visual  field  the  limits 
are  accurately  noted  in  angular  degrees  by  means  of  an 
instrument  designed  for  the  purpose.  This  instrument, 
called  a  perimeter,  also  affords  a  means  of  testing  the 
power  to  perceive  colors  (color-sense).  The  perimeter 
shows  us  that  the  normal  eye  does  not  distinguish  colors 
clearly  in  the  peripheral  portions  of  the  field,  where  black 
and  white  are  still  perceptible.  The  limit  for  black  and 
white  forms  the  outer  boundary  of  the  visual  field  ;  next, 
proceeding  toward  the  center,  comes  the  limit  for  blue. 
The  power  of  recognizing  blue  therefore  extends  furthest 
toward  the  periphery,  while  the  limits  for  red  and  green 
lie  successively  nearer  the  center. 

In  using  the  perimeter  the  following  rules  must  be 
borne  in  mind,  or  the  result  will  be  of  no  value  : 

1.  The  test-objects  must  be  sufficiently  illuminated,  as 
in  testing  the  acuity  of  vision  ;  white  objects  must  be  a 
pure  white,  and  the  color  of  colored  objects  perfectly  clear 
and  distinct,  not  soiled  nor  faded  by  use.  Hence  the  test- 
objects  are  to  be  made  of  white  or  colored  paper,  about  2 
cm.  in  diameter,  and  renewed  from  time  to  time ;  they  are 
then  pasted  on  a  small  card  affixed  to  a  carrier,  which  can 
be  moved  on  the  arc  of  the  perimeter  from  the  periphery 
toward  the  center. 

2.  It  is  necessary  to  keep  a  strict  watch  on  the  patient 
to  see  that  his  eye  remains  constantly  fixed  on  the  center 
or  zero-mark  of  the  perimeter.  Unless  the  patient  is 
unusually  intelligent  or  accustomed  to  the  examination,  his 
eye  will  have  a  tendency  to  swerve  from  the  zero-point 
and  turn  toward  the  approaching  test-object,  and  he  will 
announce  that  he  sees  it.  It  is  manifest,  however,  that 
he    has   seen    it   by  direct,  not   by  indirect,  vision ;  his 


58  EXTERNAL  DISEASES  OF  THE  EYE. 

statement  is  therefore  worthless,  and  the  test  has  to 
be  applied  anew  for  that  meridian.  To  overcome  this 
troublesome  and  time-consuming  tendency  on  the  part 
of  the  patient  the  surgeon  must  take  his  stand  behind  the 
perimeter,  and  face  the  patient  and  control  him  with  his 
gaze. 

3.  When  the  color-limits  are  to  be  determined  the 
patient  must  not  be  told  the  color  of  the  test-object 
beforehand  ;  but  he  is  to  name  the  color  as  soon  as  he 
sees  the  object.  When  the  white  mark  is  used,  however, 
he  should  be  told  to  pay  no  attention  to  the  color,  but 
to  say  "  Now  "  as  soon  as  he  sees  anything  moving. 

4.  The  measurement  is  not  to  be  made  while  the  patient 
is  tired  ;  and  should  therefore  occupy  as  short  a  time  as 
possible.  When  the  eyes  are  fatigued  the  examination  is 
apt  to  show  a  narrower  field  than  really  exists. 

Ä  record-chart  (after  Förster),  with  the  outline  of  a 
normal  field  of  vision  printed  on  it,  is  used  to  record  the 
result  of  the  examination. 

A  great  variety  of  perimeters  have  been  devised.  The  one  recom- 
mended and  first  introduced  into  practice  by  Förster  is  both  simple  and 
serviceable.  It  consists  of  a  semicircle,  rotating  around  a  central  pivot, 
with  a  chin-rest  at  the  center  of  curvature  for  the  support  of  the  patient's 
chin.  A  very  good  instrument,  in  my  opinion,  has  lately  been  con- 
structed by  Ascher.  It  possesses  the  advantage  that  the  field  of  vision 
can  be  projected  and  directly  outlined  on  a  real  hemisphere,  without  the 
surgeon's  being  obliged  to  give  up  control  of  the  patient's  eyes,  as  is  the 
oasr  with  other  hemispheres.  The  hemisphere,  which  is  not  very  large 
and  easy  to  handle,  is  made  of  transparent  celluloid.  The  test-objects 
are  moved  about  on  the  outside  of  the  hemisphere  and  the  limits  of 
the  field  immediately  marked  out  with  soft  chalk,  the  patient  holding 
the  instrument  himself  in  a  comfortable  position.  [A  self-registering 
perimeter — for  example,  McHardy's — is  most  useful. — Ed.] 

Abnormalities  in  the  field  of  vision  are  often  of  great 
significance.  Besides  indicating  functional  disturbance  in 
certain  parts  of  the  retina,  they  may  lead  to  the  discovery 
of  interruptions  in  the  optic  nerve  or  in  any  part  of  the 
visual  tract  as  far  as  the  cerebral  cortex  in  the  occipital 
lobe,  or  of  disease  of  the  cortex  itself. 

Among  eye-affections,  separation  of  the  retina  from  the 
choroid  is  a  frequent  cause  of  disturbances  in  the  visual 


EXAMINATION  OF  THE  EYE  IN  DISEASE.        59 

field.  Constrictions  in  the  field  correspond  to  the  areas 
of  separation,  a  detachment  in  the  upper  portion  of 
the  retina  producing  a  constriction  in  the  lower  part  of 
the  visual  field.  Pigmentary  degeneration  of  the  retina, 
under  certain  circumstances,  produces  marked  concentric 
constrictions.  Disseminated  scotomata  are  found  in  dif- 
fuse choroiditis;  central  scotomata  in  disease  of  the  macula 
lutea,  etc.  Atrophy  of  the  optic  nerve  from  any  cause  is 
also  followed  by  constriction  of  the  visual  field,  more  par- 
ticularly of  the  color-limits,  and  especially  the  limit  for 
green.  Disease  of  the  papillomacular  bundle  gives  rise 
to  central  scotoma.  Obscuration  of  the  same  half  of  each 
visual  field  (hemianopsia)  points  to  a  disturbance  behind 
the  chiasm,  in  the  domain  of  the  right  tractus,  or  in  the 
pathway  to  the  right  cortex,  or  in  the  cortex  itself. 
Speaking  generally,  homonymous  defects  in  the  field  of 
vision  indicate  disease  of  the  opposite  hemisphere,  at  some 
point  posterior  to  the  chiasm.1 

10.  Measuring  the  Light=sense. 

The  practice  of  measuring  the  light-sense,  which  is 
necessary  in  a  limited  number  of  cases,  was  also  introduced 
by  Förster,  who  designed  a  suitable  instrument  for  the 
purpose,  the  photometer.2 

Whereas  a  normal  eye  can  read  the  letters  on  a  type- 
card  even  when  the  light  is  comparatively  poor,  there  are 
certain  diseases  in  which  reading  is  possible  only  in  a 
good,  strong  light.  These  diseases  chiefly  affect,  not  the 
nervous  pathway  behind  the  retina  and  in  the  course  of 
the  optic  nerve,  but  the  perceptive  layer  itself,  the  special- 
ized epithelium,  whether  they  originate  in  the  retina  or 
are  secondary  to  disease  of  the  choroid.  In  syphilitic 
choroiditis  or  in  the  active  stage  of  simple  choroiditis,  in 

1  A  brief  survey  of  the  most  important  disturbances  in  the  field  of 
vision,  for  clinicians,  practising;  physicians  and  students,  fully  described 
and  illustrated,  will  be  found  in  my  Augenärztliche  Unterrichtungstafeln, 
Magnus  Heft  v.,  Breslau,  1893. 

2  More  correctly,  "  photoptometer,"  as  the  term  photometer  is  applied 
to  instruments  for  measuring  the  intensity  of  a  source  of  light. 


60  EXTERNAL  DISEASES  OF  THE  EYE. 

pigmentary  degeneration,  or  in  detachment  of  the  retina, 
the  light-sense  often  diminishes  to  a  hundredth  of  the 
normal.  The  same  is  true  in  so-called  idiopathic  night- 
blindness  (nyctalopia),  the  cause  of  which  is  probably  t<> 
be  sought  in  the  retina,  but  is  not  well  understood. 

Förster' s  photometer  consists  of  an  oblong  box  (30  cm. 
long,  22  cm.  wide,  and  17  cm.  high),  painted  black  on  the 
in  side.  One  of  the  short  sides  is  pierced  by  two  sight- 
holes  for  the  patient's  eyes,  and  a  third  opening,  through 
which  the  interior  is  illuminated  by  a  standard  candle 
enclosed  in  a  case.  The  size  of  the  opening  can  be  regu- 
lated by  means  of  a  shutter  and  screw.  On  the  opposite 
side  of  the  box  are  a  number  of  vertical  black  lines  of 
varying  thickness  on  a  white  background,  on  which  the 
light  can  be  thrown  with  varying  intensity  by  the  aid  of 
the  shutter.  The  smaller  the  opening,  and  consequently 
the  less  the  amount  of  light  needed  to  recognize  the  ver- 
tical lines,  the  better  the  light-sense.  The  size  of  the 
opening  is  read  off  on  a  scale  and  the  light-sense  com- 
puted from  it.  If,  for  example,  a  patient  requires  an 
opening  10  times  as  large  as  suffices  for  a  normal  eye 
to  distinguish  the  marks,  his  light-sense  is  10  times  less, 
or  yL  0f  the  normal. 

It  is  an  essential  condition  of  trustworthy  results  that 
the  patient's  eyes  be  thoroughly  rested  and  accustomed  to 
the  dim  light.  He  should  therefore  be  in  a  dark  room 
at  least  ten  minutes  before  the  examination  is  begun. 

ii.  Testing  the  Color=sense. 

It  has  been  found  that  among  men  from  4  to  5  per  cent, 
are  color-blind,  although  among  women  the  percentage  is 
almost  zero.  As  the  most  usual  form  is  red-green  color- 
blindness, which  disqualifies  a  man  for  service  as  a  sailor 
or  railroad  employee,  it  is  necessary  to  test  with  scien- 
tific accuracy  the  power  of  perceiving  color.  Many  color- 
blind persons  have  learned  by  practice  to  conceal  their 
infirmity,  and  are  able  to  name  any  given  color  correctly 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         61 

without  really  seeing  it;  hence  certain  precautions  are 
needful  in  making  an  accurate  test  of  the  color-sense. 
If,  for  example,  a  color-blind  person  is  given  a  red  and 
a  green  object  he  will,  as  a  rule,  be  able  to  distinguish 
between  them  by  the  difference  in  the  amount  of  light 
they  reflect ;  but  if  the  confusion-colors  are  added  he  will 
find  it  very  difficult,  if  not  impossible,  to  pick  out  the 
required  color.  As  red  and  green  appear  to  a  color- 
blind person  like  shades  of  gray,  yellow,  and  blue,  he 
is  apt  to  confuse  them  with  those  shades.  The  follow- 
ing methods  of  examination  are  employed  : 

1.  A  large  number  of  variously  colored  skeins,  about 
as  large  as  the  little  finger,  are  prepared,  comprising  the 
colors  of  the  spectrum  and  numerous  shades  of  gray,  brown, 
and  rose.  The  yarns  being  heaped  up  before  the  subject 
in  a  confused  mass,  a  light-green  test-skein  is  first  laid 
down  beside  them  in  good  daylight,  on  a  colorless  back- 
ground (such  as  a  black  table).  If  the  subject  under  ex- 
amination is  blind  for  red  and  green  he  will  choose  some 
confusion-colors  [■/.  e.,  with  or  without  the  greens — grays, 
drabs,  stone-colors,  fawns,  pinks,  yellows].  Next  a  rose 
skein  is  laid  on  the  table :  A  person  with  red-green  blind- 
ness will  now  choose  blue  shades,  because  he  does  not  see 
the  red  in  the  rose  skein  ;  while  one  who  is  blind  for  blue 
and  yellow  will  choose  red  skeins,  because  he  does  not  see 
the  blue  in  the  rose.  This  method  was  first  proposed  by 
Seebeck  and  more  fully  developed  by  Holmgren  ;  but  it 
fails  to  detect  many  cases  of  color-blindness  in  individuals 
who  have  trained  themselves  to  recognize  colors. 

2.  The  so-called  tissue-paper  contrast-test  may  be  used. 
If  a  black  or  gray  letter,  on  a  colored  background,  is 
covered  with  tissue-paper,  it  appears  to  have  the  comple- 
mental  color  of  the  background  ;  green,  for  example,  if  the 
background  is  bright  red.  The  greenish  tint,  however,  is 
very  delicate  and  cannot  be  perceived  by  a  color-blind 
person.  The  thickness  of  the  tissue-paper  must  be  ac- 
curately regulated,  and  none  but  an  expert  can  be  trusted 
to  perform  the  test.     [This  test  is  not  of  much  practical 


62  EXTERNAL  DISEASES  OF  THE  EYE. 

value. — Ed.]     Pflüger's  tablets  for  the  detection  of  color- 
blindness are  constructed  on  this  principle. 

3.  Another  method  of  detecting  color-blindness  consists 
in  the  use  of  colored  figures  on  a  colored  background,  con- 
fusion-colors being  used  for  both  figures  and  background, 
and  the  shape  of  the  figures  obscured  as  much  as  possible 
by  a  mosaic  arrangement  of  dots,  so  that  only  the  color  can 
be  plainly  perceived.  The  dots  forming  the  figures  must 
be  of  the  same  color  as  the  background.  Stilling  has 
utilized  this  method  in  his  "  pseudoisochromatic  plates 
for  the  detection  of  color-blindness."  The  test  is  a  delicate 
one  and  quite  simple  in  its  application,  so  that  it  need  not 
be  performed  by  an  expert.  By  its  aid  we  can  detect  any 
diminution  in  the  color-sense  for  a  particular  color,  as  well 
as  total  color-blindness.  The  plates  also  contain  figures 
for  the  detection  of  persons  who  pretend  color-blindness. 
They  are  to  be  commended  for  the  accurate  determination 
of  disturbances  of  the  color-sense. 


12.  Examination  for  Disturbances  of  Mobility. 

In  paralysis  of  the  eye-muscles  the  ordinary  test  of 
requiring  the  patient  to  look  up  and  down  and  to  either  side 
is  not  sufficiently  accurate,  and  must  be  supplemented  by 
a  careful  study  of  the  double  images  which  occur.  Ob- 
viously, if  the  left  abducens,  for  instance,  is  completely 
paralyzed,  it  is  easy  enough  to  demonstrate  that  the  left 
eye  fails  to  move  to  the  left  when  the  patient  is  told  to 
fix  an  object  held  in  front  of  him  and  a  little  to  the  left 
side.  In  this  case  there  will  also  be  a  deviation  of  the  eye 
toward  the  nasal  side,  because  the  internal  rectus  prepon- 
derates (convergent  squint) ;  but  if  the  paralysis  is  only 
partial,  wTe  must  investigate  the  double  images  before  we 
can  make  an  accurate  diagnosis,  especially  if,  as  frequently 
happens,  several  muscles  are  involved. 

If  the  paralysis  is  recent,  the  patient  usually  consults  an 
oculist  for  the  diplopia  and  accompanying  visual  vertigo  ; 
but  as  the  paralysis  progresses,  the  diplopia  becomes  less 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         63 

noticeable,  although  it  is  possible  even  in  old  cases  to 
detect  its  presence  by  using  suitable  means — holding  a 
red  glass  in  front  of  the  eye,  or  producing  vertical  diplo- 
pia with  an  appropriate  prism. 

In  order  to  understand  the  various  forms  of  diplopia 
which  occur  in  paralyses  of  the  ocular  muscles  it  is  only 
necessary  to  remember  the  origins  and  insertions  of  the 
external  eye-muscles.  The  accompanying  diagram  (Fig. 
A),  which  the  student  can  at  any  time  sketch  for  himself, 
will  help  to  make  the  matter  clear. 


x* 


Bect.e&t». 
Rectsup^..... 


Obltnf. 

„Oblsup. 
„...RecUTit. 
.-..Jftectinf. 


Fig.  A. 


The  course  of  the  recti  muscles  is  easily  remembered  by 
bearing  in  mind  that  they  all  arise  at  the  apex  of  the 
orbit,  around  the  optic  foramen,  and  are  inserted  into  the 
sclera  7-8  mm.  behind  the  sclerocorneal  junction.  The 
plane  of  the  internal  and  external  recti  coincides  with  the 
horizontal  meridian  ;  while  the  plane  of  the  superior  and 
inferior  recti  forms  an  acute  angle  with  the  vertical 
meridian  of  the  globe,  as  their  insertion  is  a  little  more 
temporal  than  their  origin. 

The  superior  oblique  (or  trochlear)  also  takes  its  origin 
at  the  optic  foramen  and  proceeds  forward  parallel  to,  and 
a  little  above  the  internal  rectus  until  it  reaches  the 
trochlea,  or  pulley  of  the  superior  oblique,  from  which 
point  its  direction,  backward  and  outward,  really  begins. 


64  EXTERNAL  DISEASES  OF  THE  EYE. 

Practically,  therefore,  it  passes  around  the  globe  in  that 
direction  (backward,  outward,  and  downward),  beneath 
the  superior  rectus,  and  is  inserted  behind  that  muscle, 
near  the  horizontal  meridian,  and  a  little  behind  the 
equator. 

The  inferior  oblique  arises  in  front,  on  the  inner  floor 
of  the  orbit,  opposite  the  lower  extremity  of  the  lachrymal 
crest  of  the  lachrymal  bone.  It  embraces  the  globe  from 
below,  in  the  same  plane  with  the  superior  oblique,  and  is 
inserted  behind  and  above,  on  the  outer  aspect  of  the 
globe,  between  the  insertion  of  the  external  rectus  and  the 
optic  nerve. 

If  we  imagine  a  gigantic  orbit  with  a  globe  of  such 
dimensions  that  we  can  just  encircle  it  with  both  arms, 
we  can  imitate  the  action  of  the  recti  muscles  by  taking  a 
position  to  the  nasal  side  of  the  optic-nerve  entrance,  at 
the  point  x  on  the  diagram.  By  embracing  the  globe  in 
a  horizontal  plane  we  should  imitate  the  action  of  the  in- 
ternal and  external  recti  ;  if,  on  the  other  hand,  we  were 
to  embrace  the  globe  in  a  vertical  plane,  we  should  imitate 
the  action  of  the  superior  and  inferior  recti.  Incidentally 
we  should  notice  that  the  globe  had  a  tendency  to  slip  side- 
wavs,  as,  from  our  position  on  one  side,  we  should  be 
holding  it  obliquely. 

To  imitate  the  action  of  the  oblique  muscles  Ave  should 
have  to  take  our  stand  on  the  inner  portion  of  the  orbit, 
in  front,  at  the  point  x  x  in  the  diagram,  and  grasp  the 
globe  in  a  direction  from  before  outward  and  backward,  so 
that  our  hands  would  almost  meet  on  the  outer  and  pos- 
terior portion. 

If  we  further  imagine  this  gigantic  eye  to  be  easily 
movable  about  its  axis  we  shall  obtain  a  clear  idea  of  the 
actions  of  the  various  muscles  by  turning  it  in  imagina- 
tion with  our  hands,  as  described.  If  we  imagine  our- 
selves, with  our  hands  on  the  insertions  of  the  muscles, 
turning  the  globe  from  the  three  points  mentioned,  we 
note  the  following  effects  : 

In  the  first  position,  with  our  arms  embracing  the  globe 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         65 

in  the  horizontal  meridian,  we  simply  turn  it  to  and  fro, 
the  cornea  moving  from  one  canthus  to  the  other  in  a  hori- 
zontal plane.  If  we  imitate  the  action  of  the  superior  and 
inferior  recti,  we  note  that  when  we  tilt  the  globe  upward 
the  cornea  does  not  move  directly  upward,  hut,  owing  to 
our  somewhat  nasal  position,  slightly  inward  as  well,  and 
the  upper  extremity  of  the  vertical  meridian  is  inclined 
slightly  inward  (toward  the  nose).  If,  on  the  other  hand, 
we  exert  a  downward  pull  with  the  arm  which  represents 
the  inferior  rectus,  the  globe  is  rotated  downward,  the 
cornea  is  drawn  slightly  inward,  and  the  lower  extremity 
of  the  vertical  meridian  is  brought  nearer  the  center  of 
the  eye — i.  e.,  inclined  inward  (toward  the  nose). 

If  we  imitate  the  action  of  the  oblique  muscles  (from 
the  position  x  x),  the  eye  being  in  the  primary  position, 
the  pull  of  the  superior  oblique  gives  the  cornea  an  out- 
ward and  downward  direction,  because  the  globe  is  ele- 
vated behind  ;  and  the  pull  of  the  inferior  oblique  gives 
the  cornea  an  outward  and  upward  direction,  because  the 
globe  is  depressed  behind. 

But  if  we  suppose  the  eye  to  be  looking  outward 
(toward  the  temple)  (compare  Fig.  A),  so  that  the  cornea 
is  in  the  outer  canthus,  we  can  readily  appreciate  that  the 
oblique  muscles  will  have  an  almost  exclusively  rotatory 
action,  with  very  little  elevation  or  depression.  If,  on  the 
contrary,  we  suppose  the  eye  to  be  turned  inward  (toward 
the  nose)  and  looking  directly  at  us,  the  oblique  muscles 
will  act  almost  exclusively  as  elevators  or  depressors. 

As  to  the  direction  in  which  the  oblique  muscles  rotate 
the  eyeball,  the  effect  of  the  superior  oblique  is  to  incline 
the  upper,  that  of  the  inferior  oblique  the  lower,  extremity 
of  the  vertical  median  inward.  By  rotation  is  meant 
turning  of  the  eye  about  any  axis  running  from  before 
backward  through  the  lobe. 

Returning  once  more  to  the  superior  and  inferior  recti, 
we  can  readily  understand  that  this  pair  is  also  capable  of 
rotating  the  eye  when  it  is  directed  inward,  but  not  as 
much  as  the  oblique  muscles.     When  the  eye  is  directed 

5 


66  EXTERNAL  DISEASES  OF  THE  EYR 

outward  (toward  the  temple),  the  superior  and  inferior 
recti  act  exclusively  as  elevators  or  depressors. 

Evidently,  then,  we  need  only  to  know  the  course  of 
the  various  muscles  in  order  to  understand  their  actions 
and  the  position  they  give  to  the  cornea. 

The  internal  rectus  is  an  adductor,  the  external  an  ab- 
ductor of  the  cornea. 

The  superior  rectus  elevates  the  cornea  and  inclines  the 
upper  extremity  of  the  vertical  meridian  inward  when  the 
eye  is  in  the  primary  position. 

The  inferior  rectus  depresses  and  slightly  adducts  the 
cornea  and  inclines  the  lower  extremity  of  the  vertical 
meridian  inward  when  the  eye  is  in  the  primary  position. 

The  superior  oblique  depresses  and  abducts  the  cornea 
(rotating  it  downward  and  outward)  and  inclines  the  upper 
extremity  of  the  vertical  meridian  inward. 

The  inferior  oblique  elevates  and  abducts  the  cornea 
(rotating  it  upward  and  outward)  and  inclines  the  lower 
extremity  of  the  vertical  meridian  inward. 

To  draw  the  cornea  directly  upward  from  the  primary 
position,  the  superior  rectus  and  inferior  oblique  must 
cooperate  ;  to  turn  the  gaze  directly  down  ward,  the  coopera- 
tion of  the  inferior  rectus  and  superior  oblique  is  required  ; 
while  adduction  and  abduction  from  the  primary  position 
are  effected  solely  by  the  action  of  the  internal  rectus  and 
external  rectus  respectively. 

Having  now  firmly  fixed  the  actions  of  the  muscles  in 
our  mind,  we  are  ready  to  take  up  the  analysis  of  the 
double  images  which  occur  in  paralysis.  Let  us  again 
suppose  the  left  external  rectus  (abducens)  to  be  par- 
alyzed. If  a  test-object — a  candle,  for  instance — is  held 
before  the  patient  in  a  dark  room,  in  such  a  position 
that  he  must  turn  his  eyes  to  the  left  in  order  to  fix 
it  without  turning  his  head,  he  will  tell  us  that  lie 
sees  two  images  of  the  flame  side  by  side  on  the  same 
level.  This  may  be  explained  as  follows  :  The  normal 
right  eye  fixes  the  flame  correctly  ;  but  the  left  eye  can- 
not be  turned  to  the  left  far  enough  for  the  image  of 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         67 

the  flame  to  be  formed  on  the  fovea  centralis  (as  in  the 
right  eye),  and  the  image  falls  instead  on  a  point  of  the 
retina  a  little  to  the  nasal  side  of  the  fovea  centralis.  An 
image  formed  to  the  nasal  side  of  the  fovea  centralis  will 
be  projected  outward — L  e.,  to  the  temporal  side  of  the 
visual  line.  It  is  situated  in  the  visual  field,  on  the  tem- 
poral side  of  the  fixation-point,  the  deviation  toward  the 
temple  in  the  visual  field  being  proportional  to  the  devia- 
tion of  the  retinal  image  from  the  fovea  centralis  toward 
the  nose.  If  the  light  is  moved  still  further  toward  the 
left,  the  right  eve  will  follow  it ;  while,  on  the  other 
hand,  only  the  retinal  image  of  the  left  eye  will  move 
nasalward  and  its  false  image  correspondingly  temporal- 
ward — L  e.,  to  the  left.  The  false  image  (image  of  the 
aifected  eye)  is  so  called  because  it  is  indistinct,  for  images 
formed  outside  the  macula  lutea  are  faint,  becoming  more 
and  more  indistinct  as  the  periphery  is  approached.  In 
the  case  before  us  the  patient  sees  the  image  of  the  right 
eye  in  its  proper  place ;  that  of  the  left  eye,  on  the  con- 
trary, to  the  left  or  temporal  side — there  is  homonymous 
or  simple  diplopia. 

If  the  candle  is  moved  back  toward  the  right  on  the 
same  level,  the  two  images  begin  to  approach  each  other ; 
and  when  a  point  directly  opposite,  or  slightly  to  the  nasal 
side  of  the  center  of  the  eye  has  been  reached,  the  patient 
sees  single,  as  he  also  does  when  looking  still  further  to 
the  right.  It  appears,  therefore,  that  diplopia  occurs 
only  when  the  test-object  is  brought  within  the  field  of 
action  of  the  palsied  muscle ;  the  error  can  be  corrected 
by  turning  the  head  (instead  of  the  eyes)  to  the  left. 

In  paralysis  of  the  left  external  rectus  abducens,  which 
under  normal  conditions  controls  the  outward  movement 
of  the  cornea,  the  false  image  lies  to  the  left  of  the  real 
image.  For  similar  reasons,  on  the  other  hand,  if  the 
internal  rectus  of  the  left  eye  is  paralyzed,  the  false  image 
is  displaced  to  the  right — in  that  case  there  is  heterony- 
mous or  crossed  diplopia. 

If  the  superior  rectus  is  affected,  the  eye  lags  in  eleva- 


68  EXTERNAL   DISEASES  OF  THE  EYE. 

tion  and  slightly  in  abduction,  so  that  the  retinal  image  is 
formed  below,  and  a  little  to  the  outer  side  of  the  fovea 
centralis.  Hence  the  image  of  the  left  or  affected  eve  lies 
above,  and  a  little  to  the  inner  side  of  that  of  the  right  or 
sound  eye,  its  upper  extremity  being  inclined  slightly  in- 
ward from  failure  of  the  superior  rectus  to  rotate  the  eve- 
ball.  The  absence  of  rotation  becomes  more  marked  as 
the  eye  is  turned  further  inward,  because  the  pull  of  the 
superior  rectus  is  more  oblique  in  adduction  and  therefore 
exercises  a  more  pronounced  torsion-effect.  If,  on  the 
contrary,  the  eye  is  turned  outward,  the  torsion-effect  <>{" 
the  muscle  does  not  come  into  play  at  all,  its  only  effect 
being  to  elevate  the  cornea,  and  the  vertical  distance  be- 
tween the  two  images  is  therefore  increased.  Lateral  sepa- 
ration of  the  images,  which  is  not  great,  is  most  pronounced 
when  the  eye  is  in  the  primary  position. 

If  we  were  to  investigate  the  double  images  in  paralysis 
of  the  oblique  muscles  in  the  same  way,  we  should  arrive 
at  the  following  general  conclusion  :  The  direction  in 
which  the  false  image  separates  from  the  true  image 
always  corresponds  to  the  direction  in  which  the  eye  is 
moved  by  the  affected  muscle;  or,  better:  The  image  of 
flu  affected  eye  is  always  projected  in  the  direction  toward 
which  (if  it  wee  able  to  perform  its  function)  the  paralyzed 
muscle  would  rotate  the  cornea  ;  <tn<t  the  image  is  inclined  in 
the  direction  toward  which  the  affected  muscle  in  the  s<>nn<l 
state  would  incline  the  vertical  meridian. 

Let  us  take  another  example  :  Suppose  the  left  superior 
oblique  is  paralyzed.  Its  unaided  action  on  the  eye  in  the 
primary  position  is  to  rotate  the  cornea  outward  and  down- 
ward and  to  tilt  the  upper  end  of  the  vertical  meridian 
inward.  This  is  precisely  the  direction  toward  which  the 
image  of  the  left  eye  is  projected  :  it  is  found  to  the  outer 
(temporal)  side  of,  and  below,  the  image  of  the  right  eye, 
with  its  upper  end  inclined  inward,  toward  the  nose  (com- 
pare Fig.  B).  The  double  images  in  paralysis  of  the 
superior  oblique  are,  of  course,  found  in  the  lower  portion 
of  the  field  of  fixation,  since  the  muscle  is  a  depressor  of 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         (59 

the  cornea,  its  depressing  action  being  most  marked  when 
the  eye  is  directed  inward.  Hence,  when  the  light  is  held 
low  and  toward  the  right,  the  vertical  distance  between  the 
images  is  greater  than  it  is  when  the  eye  is  forced  to  turn 
outward  and  downward.  When  the  eye  is  directed  out- 
ward and  downward,  the  superior  oblique  rotates  the  ver- 
tical meridian  inward  ;  hence  the  image  of  the  left  eye 
exhibits  a  greater  nasal  inclination  above  and  the  vertical 
separation  is  at  the  same  time  diminished.  The  image  of 
the  left  eye  therefore  always  remains  to  the  left  of  that  of 
the  right ;  in  other  words,  there  is  homonymous  diplopia, 
because  the  superior  oblique  is  an  abductor. 

In  paralysis  of  the  inferior  oblique,  which,  when  it  nor- 
mally acts  alone,  rotates  the  cornea  outward  and  upward 
and  tilts  the  upper  extremity  of  the  vertical  meridian 
toward  the  temporal  side,  the  image  of  the  affected  eye  is 
found  to  the  outer  side  and  above  its  fellow,  with  a  tem- 
poral inclination  in  its  upper  extremity.  Again,  the  ver- 
tical separation  of  the  double  images  is  greatest  when 
the  eye  is  turned  inward,  and  their  obliquity  most 
pronounced  when  the  eye  is  turned  toward  the  temporal 
side.  The  double  images  are  homonymous,  and  the 
diplopia  must  be  sought  in  the  upper  portion  of  the 
field  of  fixation. 

In  paralysis  of  the  superior  rectus,  which  normally 
rotates  the  cornea  upward  and  inward  and  tilts  the  upper 
extremity  of  the  vertical  meridian  toward  the  nose,  the 
image  of  the  affected  eye  is  found  above  and  some- 
what to  the  inner  side  of  its  fellow,  with  a  slight  nasal 
inclination  above.  In  abduction  the  nasal  inclination 
is  diminished  and  the  vertical  separation  of  the  images 
increased. 

In  paralysis  of  the  inferior  rectus,  which  normally 
rotates  the  cornea  downward  and  slightly  inward  and  tilts 
the  lower  extremity  of  the  vertical  meridian  toward  the 
nose,  the  image  of  the  affected  eye  is  found  below  and  a 
little  to  the  inner  side  of  its  fellow,  with  a  slight  nasal 
inclination  in  the  lower  extremity.     The  nasal  inclination 


70  EXTERNAL  DISEASES  OF  THE  EYE. 

is  distinct  only  when  the  gaze  is  directed  inward  ;  it  dimin- 
ishes when  the  eye  is  turned  toward  the  temple,  while  the 
vertical  separation  of  the  images  increases. 

To  determine  with  certainty  which  of  the  two  images 
belongs  to  the  right  and  which  to  the  left  eye,  a  red  lens 
is  held  before  one  of  them.  The  image  of  the  eye  that 
lias  the  red  lens  before  it  appears  red,  while  the  other  lias 
its  normal  color. 

It  is  essential  to  determine  in  which  eye  the  paralysis 
exists,  or  whether  both  eyes  are  affected.  This  is  deter- 
mined by  the  following  rule  :  That  image  is  false  and  be- 
longs to  the  diseased  eye  which  travels  away  from  the  other 
image  in  approximately  the  same  direction  as  that  in  which 
tin'  test-light  is  moved;  for  the  hurrying  onward  of  the 
image  and  the  lagging  of  the  eye  from  paralysis  are 
correlated  phenomena. 

If,  for  example,  we  find  that  the  image  of  the  left  eve 
travels  faster  than  that  of  the  right  in  the  same  direction 
as  the  light  when  it  is  moved  toward  the  left,  the  paralysis 
is  in  the  left  eye  and  the  left  external  rectus  (abducens)  is 
paralyzed.  If  we  now  move  the  light  toward  the  right — 
possiblv  in  the  examination  of  the  same  patient — and  the 
image  of  the  right  eye  travels  faster  than  that  of  the  left, 
we  conclude  that  the  right  external  rectus  (abducens)  is 
also  paralyzed. 

If,  when  the  light  is  raised,  one  of  the  double  images 
also  moves  upward,  and  moreover  still  higher  upward,  we 
conclude  that  the  higher  the  light  is  elevated  this  image, 
travelling  in  advance  upward,  belongs  to  the  paralyzed 
eye,  etc. 

In  order  to  make  an  accurate  analysis  of  the  double 
images  in  a  given  case  it  is  essential  that  their  positions 
should  be  indicated  on  a  diagram — for  example,  like  the 
one  shown  in  Fig.  B — which  is  intended  to  illustrate 
paralysis  of  the  oblique  muscles  and  of  the  superior  and 
inferior  recti.  For  this  purpose  a  cross  is  constructed  of 
two  lines  and  the  position  of  the  double  images  is  sought 
for  in  nine  places  with  the  aid  of  the  test-light  and  marked 


Beet,  sup.  links 

7!  X  \l. 

\ 


\ 


I  I 


nasaZ 


spuodutdg. 


v- -H 


I    temporal 

/JfDSVU 


71         •         K 


i 


Obi.  inf. 'Utiles 


L. 

l'       \' 


nasal 


qDdodwzi 


.j — , 


temporals 


^DSTTU 


syinqjurgootf 


Fig.  B. 


72  EXTERNAL  DISEASES  OF  THE  EYE. 

on  the  diagram  as  follows  :  First,  in  the  center,  then  above 
and  below  and  right  and  left,  corresponding  to  the  cross, 
and  then  again  right,  and  the  left  above  and  right  and 
left  below.  It  is  better  for  the  surgeon  to  mark  the  posi- 
tions of  the  images  as  they  are  given  him  by  the  patient, 
who  sits  in  front  of  him.  Thus,  the  image  of  the  left  eye, 
which  separates  to  the  left  in  paralysis  of  the  external 
rectus  (abducens),  is  marked  in  the  diagram  to  the  right  as 
the  snrgeon  stands  facing  the  patient,  etc.  Sometimes  the 
patient  is  asked  to  mark  the  positions  of  the  double  images 
himself;  the  appearance  of  the  chart  in  that  case  is  quite 
different,  the  image  of  the  left  eye  (in  the  example) 
appearing  on  the  left  side  of  the  chart,  instead  of  on  the 
right.  Hence  it  is  necessarv  to  know  how  the  diagram 
was  made,  and  it  must  never  be  neglected  to  mark  which 
side  is  right  and  which  left.  If  the  surgeon  records  the 
positions  of  the  images,  /'.  (right)  must  be  written  in  the 
upper  left-hand  corner ;  if  the  patient  does  the  marking, 
r.  is  put  in  the  upper  right-hand  corner.  A  glance  at  the 
position  of  the  letters  r.  and  /.  in  Fig.  B  informs  us  that 
the  positions  of  the  double  images  were  recorded  by  the 
surgeon. 

Woinow1  has  followed  this  method  in  his  tables 
showing  the  double  images  in  paralyses  of  the  eye- 
muscles  ;  these  tables  are  much  to  be  commended  for 
purposes  of  diagnosis,  especially  in  cases  in  which  sev- 
eral muscles  are  involved.  Woinow  gives  a  number  of 
examples  of  such  multiple  paralyses  to  facilitate  their 
diagnosis. 

I  have  emphasized  this  matter  of  the  different  methods 
of  recording  the  phenomena  of  diplopia  because  it  is  a 
frequent  source  of  confusion  to  the  beginner. 

When  the  paralysis  has  existed  for  some  time  it  is  often 
very  difficult  to  make  a  correct  diagnosis,  because  the 
patients  have  learnt  by  practice  to  suppress  one  of  the 
double   images.      Nevertheless   they  often    complain    of 

1  Woinow,  Veher  das  Verhalten  der  Doppelbilder  bei  Augenmuskellähmungen, 
in  15  Tafeln  dargestellt,  Vienna,  1670. 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         73 

visual  disturbances,  because  in  certain  rotations  of  the  eye- 
ball the  diplopia  still  confuses  them.  For  this  reason  one 
must  examine  with  especial  care  in  these  directions,  down 
and  in,  for  example,  in  paralysis  of  the  superior  oblique ; 
and  by  holding  a  prism  in  the  appropriate  position  in  front 
of  the  eye  the  diplopia  in  such  cases  may  be  developed. 
Suppose  there  is  an  old  paralysis  of  the  left  external 
rectus  (abducens).  The  patient  does  not  see  double  with 
a  red  glass,  even  in  the  region  of  diplopia  (to  the  left 
of  the  median  line) ;  but  if  a  prism  of  about  10°  is  placed 
before  the  eye,  with  the  base  up  or  down,  so  as  to  produce 
vertical  diplopia,  he  at  once  becomes  conscious  of  a  double 
image,  because  the  image  which  has  been  displaced  by  the 
prism  now  appears  in  an  unusual  location  on  the  retina 
and  is  at  once  perceived  by  the  patient.  A  glass  rod  has 
been  suggested  for  such  cases  by  Maddox  ;  it  may  also  be 
used  for  recent  cases.  Such  a  rod,  or  a  series  of  rods, 
lying  side  by  side  and  colored  red,  makes  the  flame  of  a 
candle  appear  like  a  long  red  line,  which  impresses  itself 
more  sharply  on  the  patient's  consciousness  and  brings 
out  the  exact  position  and  obliquity  of  the  double  image. 
The  study  of  the  double  images  enables  us  to  dis- 
tinguish between  paralytic  and  concomitant  squint.  Con- 
comitant or  ordinary  squint  depends  upon  not  a  paralysis, 
but  an  abnormal  position  of  the  eye  which  is  not  limited 
in  its  rotations.  In  convergent  squint,  for  instance,  the 
power  of  adduction  may  be  increased  beyond  the  normal, 
the  excess  corresponding  to  the  amount  by  which  abduc- 
tion is  diminished,  resulting  sometimes  in  the  complete 
disappearance  of  the  cornea  in  the  inner  canthus  during 
vigorous  adduction.  The  eye  does  not  lag  behind  its  fel- 
low nor  fail  to  accompany  it  in  all  its  movements  ;  always, 
however,  maintaining  the  same  abnormal  position.  The 
double  images,  if  there  be  any  at  first,  correspond  to  these 
conditions  ;  the  distance  between  them  remains  constant  in 
whatever  direction  the  eye  be  turned,  and  in  a  short  time 
the  diplopia  disappears  altogether,  as  the  squinting  eye 
learns  to  suppress  its  image. 


74  EXTERNAL  DISEASES  OF  TUE  EYE. 

Detection  of  Malingerers. 

Examination   for   (Simulated)   Amblyopia. — 

The  detection  of  pretended  amblyopia,  or  exaggeration 
of  defective  eyesight,  is  a  task  requiring  some  skill  on  the 
part  of  the  examiner. 

As  some  responsibility  attaches  to  the  performance  of 
the  test,  a  review  of  the  methods  employed  will  not  be 
amiss.  Either  to  escape  military  service,  or,  more  fre- 
quently, to  establish  a  claim  for  damages,  the  subject 
under  examination  attempts,  by  giving  wrong  answers,  to 
make  his  eyesight  appear  worse  than  it  really  is.  A 
claimant  for  damages  exaggerates  the  injury  in  the  hope 
of  obtaining  more  damages ;  the  recruit  wishes  to  escape 
conscription  on  account  of  defective  eyesight ;  the  state- 
ments of  hysterical  patients  are  often  proved  to  be  incorrect. 

It  is  natural  to  suspect  malingering  if  the  result  of  the 
.subjective  examination  fails  to  agree  with  the  result  ob- 
tained by  objective  tests — /.  e.,  if  function  is  claimed  by 
the  patient  to  be  abnormal  where  nothing  structurally  ab- 
normal is  found.  But  it  must  not  be  forgotten  that  con- 
genital  amblyopia  occurs  with  perfectly  normal  anatomic 
conditions.  Unilateral  or  bilateral  amblyopia  is  met  with 
particularly  in  hypermetropic  persons,  with  otherwise 
healthy  eyes,  and  even  appropriate  lenses  fail  to  effect 
any  improvement. 

Complete  blindness  of  both  eyes  is  rarely  simulated  ; 
but  frequently  blindness  of  one  eye  is.  In  the  latter  case 
the  simulation  is  more  easily  exposed  than  if  defective 
vision  only  is  claimed  for  one  or  both  eyes.  If  blind- 
ness of  one  eye  is  claimed,  pupil-contraction  to  direct 
light-stimulus  and  the  consenual  contraction  of  the  other 
eye  (contraction  of  the  pupil  of  the  other  eye  when  light 
falls  on  the  eye  under  examination)  can  be  investigated 
with  great  care  ;  but  there  are  rare  cases  of  pupillary 
reaction  to  light  in  both  eyes,  although  one  of  them  is  ab- 
solutely sightless.  On  the  other  hand,  a  pupil  may  fail  to 
contract  on  exposure  to  light,  though  vision  is  perfect, 


-EXAMINATION  OF  THE  EYE  IN  DISEASE         75 

because  the  iris  is  paralyzed  or  fixed  by  synechise.     For 
these  reasons  it  is  better  to  adopt  the  following  methods  : 

1.  The  patient  is  asked  to  read  while  a  card  is  held 
vertically  against  the  book  in  the  median  plane  in  such  a 
way  as  to  divide  the  page  into  two  columns.  If  the  sub- 
ject is  really  blind  of  one  eye  he  will  read  only  the  column 
opposite  his  sound  eye;  but  if  he  is  pretending  he  will 
read  both  columns.  Sometimes  a  pencil  or  a  ruler  held 
against  the  page  suffices  to  convict  the  malingerer,  for  it 
does  not  disturb  his  reading  ;  while  if  he  were  really  blind 
of  one  eye  he  would  leave  out  the  words  covered  by  the 
pencil.  An  experienced  malingerer  often  betrays  himself 
at  the  very  beginning  of  the  examination  by  rapidly 
closing  the  eye  he  claims  to  be  blind,  in  order  to  get  his 
bearings.  The  examiner  should  be  constantly  on  the  look- 
out for  this  maneuver,  whatever  method  be  used. 

2.  The  subject  is  taken  into  a  dark  room  and  a  lighted 
candle  is  slowly  moved  from  the  sound  eye  toward  its 
fellow.  If  the  patient  perceives  the  light  after  it  has 
become  hidden  from  the  sound  eye  by  the  intervening 
bridge  of  the  nose — as  seen  by  the  shadow  cast  by  the 
latter — it  is  proof  that  he  sees  it  with  the  eye  he  claims 
to  be  blind.  This  method  often  fails  to  expose  a  clever 
cheat. 

3.  The  tests  performed  with  prisms  are  more  trust- 
worthy in  their  results;  they  have  been  the  means  of 
exposing  many  frauds.  If  a  prism  is  held,  with  the  base 
toward  the  temple,  before  a  person  with  normal  vision,  and 
he  is  asked  to  fix  a  test-object,  usually  the  flame  of  a  can- 
dle, a  slight  movement  of  adduction  will  be  observed  in 
the  eye  behind  the  prism.  It  is  the  natural  result  of  the 
effort  to  achieve  single  vision  ;  for  the  prism  produces  lat- 
eral diplopia  which  is  immediately  and  without  difficulty 
overcome  by  adduction.  The  impulse  to  bring  the  double 
images  together  is  so  strong  that  the  test  rarely  foils.  The 
prism  must  be  placed  before  the  supposedly  blind  eye. 
[The  same  test,  as  pointed  out  by  Priestley  Smith  and  E. 
Jackson,  may  be  used  to  detect  feigned  binocular  blind- 


76  EXTERNAL  DISEASES  OF  THE  EYE. 

ness  :  A  lighted  candle  is  placed  before  the  subject  in  a 
dark  room.  He  is  not  required  to  "look"  at  the  candle, 
being  nominally  blind  ;  but  the  candle  is  placed  about 
where  he  appears  to  be  looking.  A  prism  6u-8°  is  then 
placed  before  one  eye,  its  base,  for  example,  toward  the 
temple.  If  the  patient  sees,  the  eye  will  rotate  inward, 
and  when  the  prism  is  removed,  a  movement  of  "  recov- 
ery "  outward  will  take  place. — Ed.] 

Another  plan  is  to  place  the  prism,  base  down,  before 
the  admittedly  sound  eye  and  ask  the  patient  whether  he 
sees  one  or  two  candles.  If  both  eyes  are  sound,  the 
image  of  the  eye  behind  the  prism  is  above  that  of  its 
fellow.  If,  therefore,  the  subject  acknowledges  that  he 
sees  two  images  it  is  a  proof  that  both  eyes  are  sound. 
As  many  malingerers,  however,  are  aware  that  admission 
of  binocular  vision  would  expose  them,  the  test  must  oc- 
casionally be  varied  by  producing  diplopia  in  the  admit- 
tedly sound  eye.  For  this  purpose  a  strong  prism  (about 
15°),  with  the  base  up,  is  gradually  carried  up  from 
below  in  front  of  the  eye.  As  soon  as  the  lower  half  of 
the  pupil  is  covered  by  the  edge  of  the  prism  diplopia 
begins,  because  those  rays  which  have  passed  through  the 
prism  are  refracted,  while  the  others  enter  the  pupil  di- 
rectly. By  covering  the  other  eye  we  convince  the  sub- 
ject that  it  is  possible  to  see  double  with  one  eye.  Xow 
the  supposedly  blind  eye  is  uncovered  and  the  prism  at 
the  same  time  carried  a  little  higher,  so  as  to  cover  the 
entire  pupil.  If  the  subject  again  acknowledges  binocular 
vision,  it  is  evident  that  he  is  malingering,  and  the  visual 
acuity  of  the  pretended  blind  eye  may  even  be  tested  with 
a  type-card  without  his  suspecting  it.  The  higher  of  the 
two  images  in  the  case  described  corresponds  to  the  sup- 
posedly blind  eye.  A  naked  prism  is  the  best  for  this 
test. 

4.  A  high  convex  glass  of  about  6  D  is  placed  before 
the  sound  eye,  which  is  thereby  rendered  (artificially) 
myopic  and  cannot  read  tine  print  at  a  greater  distance 
than  about  17  cm.     The  book  is  first  held  within  that  dis- 


EXAMINATION  OF  THE  EYE  IN  DISEASE.         77 

tance,  and  then  gradually  moved  further  away.  If  the  act 
of  reading  is  found  to  be  possible  at  a  distance  greater 
than  17  cm.,  it  must  have  been  performed  by  the  other 
eye. 

Detection  is  somewhat  more  difficult  when  defective 
vision  only  is  pretended,  or  when,  as  is  frequently  done  in 
suits  for  damages,  an  attempt  is  made  to  exaggerate  an 
existing  defect,  as  when  a  subject  with  a  visual  acuity  of 
-^  claims  to  possess  only  y1^.  In  such  cases  it  should  be 
borne  in  mind  that  malingerers,  as  we  have  already  pointed 
out,  are  very  apt  to  give  contradictory  answers  when  the 
test  for  visual  acuity  is  applied  at  different  distances. 
[Any  refractive  error  should  be  corrected  by  objective 
methods  and  tests  for  acuity  of  sight  made  with  the  proper 
lenses. — Ed.]  The  cleverest  malingerer  will  find  it  diffi- 
cult always  to  pick  out  the  letters  which  correspond  to  his 
true  visual  acuity,  if  the  distance  of  the  type-card  is  rap- 
idly changed,  or  if  he  is  asked  to  read  the  test-letters  in  a 
mirror.  Besides,  he  will  show  an  inclination  to  stop  at 
the  end  of  a  line  and  claim  that  he  cannot  read  any  letters 
in  the  following  line,  whereas  really,  if  all  the  letters,  even 
the  most  difficult  ones,  in  one  line  are  read  without  diffi- 
culty, one  or  two  of  the  easiest  letters  in  the  following 
line  can  always  be  made  out.  As  we  have  said  before, 
this  should  at  least  excite  a  suspicion  of  malingering. 

Another  plan  is  to  exclude  the  admittedly  sound  eye 
from  vision,  without  the  patient's  knowledge,  by  placing 
an  appropriate  lens  before  it,  as  described  under  4.  With 
the  type-card  some  distance  off,  lenses  of  successively 
higher  degrees  of  concavity  are  placed  before  the  sound 
eye  ;  with  the  weaker  glasses  the  eye  is  still  able  to  see  the 
distant  type-card;  as  soon,  however,  as  a  lens  of  about  10 
I)  is  used,  distant  vision  is  impossible.  If  reading  is  still 
performed  it  must  be  by  the  other  eye,  which  was  claimed 
to  be  blind.  The  acuteness  of  vision  of  the  supposedly 
blind  eye  can  thus  be  measured  at  the  same  time. 

A  very  useful  device  for  the  detection  of  expert  malin- 
gerers is  the  stereoscope,  especially  as  constructed  and 


78  EXTERNAL  DISEASES  OF  THE  EYE. 

equipped  with  plates  by  M.  Burchardt.1  By  this  method, 
which  I  have  practised  for  many  years,  the  cleverest 
malingerers  can  be  exposed  and  their  true  visual  acuity 
ascertained.  The  stereoscopic  plates  are  so  arranged  that 
the  subject  under  examination  is  cjuite  unable  to  tell  with 
which  eye  he  is  reading  the  test-letters. 

To  ascertain  the  true  condition  of  affairs  when  an 
already  existing  defect  has  been  aggravated  by  an  acci- 
dental injury,  a  complete  examination  is  usually  needful. 
The  method  of  the  erect  image  furnishes  the  most  trust- 
worthy information  as  to  the  effects  of  corneal  opacities  or 
cataract  on  the  visual  acuity.  The  fact  that  a  distinct  in- 
verted image  is  obtained  does  not  necessarily  prove  that 
vision  is  good,  for  it  may  be  obtained  in  cases  in  which 
vision  is  considerably  impaired  by  astigmatism,  due  to 
corneal  opacities,  or  by  a  partial  cataract.  The  visual 
acuity  must,  therefore,  be  judged  solely  by  the  distinct- 
ness of  the  erect  image. 


DISEASES   OF   THE    LACHRYMAL   APPARATUS. 

The  source  of  the  lachrymal  secretion,  the  lachrymal 
gland,  which  is  situated  in  the  upper  outer  angle  of  the 
orbit,  close  to  the  orbital  margin,  is  rarely  attacked  by 
disease  (inflammation,  carcinoma,  sarcoma,  adenoma,  etc.). 
On  the  other  hand,  the  surgeon's  skill  and  patience  are 
often  invoked  for  the  relief  of  disturbances  in  the  drain- 
age-system, usually  in  the  form  of  stenoses. 

Excessive  flow  of  tears  (epiphora)  is  rarely  due 
primarily  to  malposition  of  the  inferior  punctum  lachrymale 
(from  eversion  or  ectropion  of  the  lower  lid).  In  most 
cases  dacryontenoHiH  is  the  basic  evil,  the  obstruction  sonic- 
times  occurring  as  high  up  as  the  canaliculi.  Not  infre- 
quently occlusion  of  the  lower  canaliculus  is  caused   by 

1  M.  Burchardt,  Praktische  Diagnostik  der  Simulation  run  Gefühlslahmung 
von  Schwerhörigkeit  mid  von  Schwachsichtigkeit,  Berlin,  1878,  Gutmann'sche 
Buchhandlung.  Mit  Stereoscop,  Tafeln,  und  genauer  Gebrauchsanwei- 
sung. 


DISEASES  OF  THE  LACHRYMAL  APPARATUS.     79 

traumatism.  If  the  lower  lid  is  torn  at  the  inner  canthus 
by  a  blow  with  the  fist  or  a  stick,  the  lower  canaliculus  is 
usually  divided.  In  rare  cases  epiphora  is  due  to  the 
presence  of  a  concretion,  usually  a  mass  of  fungus,  in  the 
lower  canaliculus ;  but  in  the  great  majority  of  cases  the 
primary  cause  is  a  stricture  in  the  taehrymonasal duct,  which 
forms  the  communication  between  the  lachrymal  sac  and 
the  inferior  meatus  of  the  nose. 

The  lachrymal  sac,  to  the  nasal  side  of  the  inner  canthus, 
lies  partially  embedded  in  a  groove  of  the  lachrymal  bone 
(fossa  sacci  lacrimalis),  which  is  bridged  over  in  front  by 
the  internal  palpebral  ligament.  This  structure  can  be 
brought  plainly  into  view  as  a  tense,  horizontal  band  by 
drawing  the  eyelid  outward,  toward  the  temple. 

The  lachrymonasal  duct  is  lodged  within  a  bony  canal, 
the  narrowest  portion  of  which  corresponds  to  the  opening 
of  the  lachrymal  sac  into  the  duct ;  this  point  is  therefore 
the  most  frequent  seat  of  stricture.  Stricture  or  occlusion 
also  occurs  in  the  lower  extremity  of  the  canal,  being 
caused  by  swelling  of  the  mucous  membrane  either  of  the 
nose  (usually  temporary)  or  of  the  duct  itself.  In  order 
to  understand  the  occurrence  of  obstructions  in  the  drain- 
age-system, which  are  particularly  common  in  the  early 
stages  of  the  disease  and  are  often  only  temporary,  it 
must  be  remembered  that  the  lachrymonasal  duct  (like  the 
inferior  meatus  of  the  nose)  contains  a  venous  plexus  re- 
sembling cellular  tissue,  which  from  its  great  liability  to 
congestion  is  very  apt  to  produce  a  temporary  occlusion. 
This  also  explains  the  excessive  flow  of  tears  in  coryza. 
Unlike  the  lachrymal  sac,  the  nasal  duct  is  surrounded  by 
bone  and  cannot  expand  when  the  secretion  accumulates 
in  excess,  so  that  swelling  of  its  vascular  lining  rapidly  pro- 
duces a  stenosis  which  may  eventually  become  permanent. 

For  these  reasons  catarrh  of  the  lachrymonasal  duct 
usually  forms  the  first  stage  of  a  long  and  tedious  process 
which  may  drag  on  for  years.  The  catarrhal  condition 
either  originates  in  the  nose  and  extends  into  the  nasal 
duct,  or  it  begins  in  the  lachrymal  sac  and  spreads  down- 


80  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  l. 

Dacryocystitis. — The  region  of  the  left  lachrymal  sac  bulges  forward  ; 
there  are  inflammation  and  pain  on  pressure ;  the  adjacent  portions  of 
the  lid  are  edematous.  A  slight  fluctuation  is  felt  at  the  apex  of  the 
tumor.  A  tear  is  seen  in  the  furrow  running  from  the  inner  canthus 
toward  the  swelling.  The  patient,  who  is  57  years  old,  has  been  in  the 
habit  of  expressing  the  mucus  and  pus  in  the  sac  at  regular  intervals  for 
the  }>ast  fifteen  years.  Inflammation  began  a  week  ago.  Subsequent 
course:  Rapture  of  the  abscess  outward,  without  formation  of  a  fistula. 

ward.  The  aggravation  of  the  epiphora  which  is  observed 
to  follow  a  fresh  attack  of  nasal  catarrh  speaks  for  the 
first  view;  while,  on  the  other  hand,  it  happens  not  in- 
frequently that  the  lachrymal  sac  is  filled  with  a  mucous 
secretion  when  there  is  no  obstruction  in  the  duct  and  the 
contents  of  the  sac  can  be  expressed  through  it  into  the 
nose.  But  the  chief  factor  in  the  etiology  of  epiphora  is 
hereditary  predisposition.  [This  observation  is  not  in  ac- 
cord with  the  Editor's  experience,  although  no  doubt 
heredity  plays  a  part.]  The  family  history  must  be  care- 
fully investigated.  Most  patients  are  reluctant  to  admit 
any  hereditary  taint,  and  prefer  to  give  a  "cold"  as  the 
cause  of  their  trouble,  just  as  they  do  for  so  many  other 
diseases.  Arrested  or  defective  development  of  the  bones 
of  the  skull,  especially  of  the  nose  and  adjacent  parts,  may 
possibly  constitute  a  predisposing  condition.  Thus,  ste- 
nosis of  the  lachrymal  canal  is  sometimes  met  with  in  sub- 
jects with  flat  noses  or  asymmetric  facial  development. 
If  we  consider,  however,  that  children  are  less  subject  to 
the  complaint  than  adults,  in  spite  of  the  fact  that  they 
have  smaller  ducts  and  suffer  more  frequently  from  coryza, 
we  are  forced  to  the  conclusion  that  something  else  besides 
mechanical  conditions  is  responsible,  probably  a  natural 
predisposition  favoring  the  growth  of  pathogenic  fungi 
in  the  lachrymal  sac  and  lachrymonasal  duct.  Such  a  pre- 
disposition is  simply  an  individual  peculiarity,  which,  like 
other  dispositions,  may  be  inherited. 

That  the  lachrymal  sac  is  often  the  abode  of  the  most  virulent  patho- 
genic germs  is  one  of  the  earliest  discoveries  of  the  bacteriologic  study 
of  the  eye.     Whether  the  presence  of  these  fungi  is  the  cause  or  the 


sä 


'A 


DISEASES  OF  THE  LACHRYMAL  APPARATUS.     81 

effect  of  the  catarrhal  condition  is  still  an  open  question.  But  if  we  con- 
sider that  suppuration  of  the  eyeball  occasionally  follows  an  operation 
for  cataract,  even  when  the  lachrymal  sac  contained  practically  no  secre- 
tion, showing  [in  the  most  unpleasant  manner]  that  such  noxious  germs 
must  have  been  originally  present  in  the  sac,  we  shall  incline  to  the 
opinion  that  the  germs  are  primary,  not  secondary,  to  the  catarrh.  These 
fungus-colonies  reveal  their  presence  in  other  ways,  for  I  cannot  conceive 
how  a  simple  catarrh  should  be  able  to  occlude  the  nasal  duct  in  places, 
narrow  as  it  is,  while  it  is  quite  easy  to  understand  that  the  mucous 
membrane  could  be  eroded  and  made  to  ulcerate  by  the  action  of  germs 
and  the  toxin  they  produce,  leading  eventually  to  strictures  and  adhe- 
sions. 

The  infectious  nature  of  the  contents  of  the  lachrymal 
sac  in  epiphora  is  further  proved  by  the  fact  that  the 
slightest  injuries  are  followed  by  suppuration  and  by  the 
occurrence,  in  most  cases,  of  conjunctivitis  and  blepharitis. 
In  itself  the  epiphora  is  hardly  serious  enough  to  induce 
either  the  surgeon  or  the  patient  to  undertake  treatment  ; 
but  the  complications  that  are  likely  to  follow  are  of 
such  grave  significance  that  treatment  is  imperatively 
demanded. 

Epiphora  is  always  the  first  symptom  to  appear.  The 
lachrymal  fluid  is  increased  in  quantity  and  accumulates  in 
the  palpebral  fissure  without  overflowing,  or  it  overflows 
and  necessitates  constant  wiping  of  the  eyes.  The  condi- 
tion is  aggravated  by  exposure  to  wind,  smoke,  or  dust.  In 
addition  to  the  inconvenience  caused  by  the  constant 
necessity  of  drying  the  eyes,  there  is  the  more  serious  dis- 
turbance to  vision,  because  the  accumulated  fluid  forms  a 
layer  over  the  cornea  which  acts  as  an  incorrect  refracting 
medium  through  which  the  optical  image  appears  distorted, 
especially  when  the  gaze  is  directed  downward.  When 
both  eyes  are  affected  the  visual  disturbance  is  particu- 
larly troublesome. 

In  spite  of  all  these  inconveniences  the  patient  very 
often  neglects  his  condition,  especially  if  he  knows  what 
an  unpleasant  treatment  is  before  him,  so  that  the  second- 
ary results  of  dacryostenosis  rarely  fail  to  appear.  On 
the  other  hand,  there  are  extraordinary  cases  in  which  a 
stenosis  occasions  but  little  inconvenience,  and  is,  in  fact, 
overlooked    until   accidentally  discovered    by  the   intro- 

6 


82  EXTERNAL   DISEASES  OF   THE  EYE. 

*  Plate  2. 

Dacryocystitis  with  Rupture  of  the  Abscess  through  the  Skin.— 
The  redness  and  swelling  in  the  region  of  the  lachrymal  sac  have  abated 
somewhat,  hut  the  upper  lid  still  exhibits  some  inflammatory  edema. 
The  patient  is  64  years  old;  he  has  been  troubled  for  some  time  with 
epiphora  of  the  right  eye.  On  May  1.  1897,  a  few  drops  of  fluid  were 
injected  into  the  nasal  duct,  and  it  was  found  that  permeability  Avas  not 
entirely  lost.  Inflammation  set  in  on  May  10,  and  two  days  later  the 
ahscess  ruptured  and  pus  was  discharged,  after  which  the  inflammation 
subsided  without  the  formation  of  a  fistula.  On  May  20  another  attempt 
was  made  to  inject  a  few  drops  of  bichlorid  solution  into  the  nasal  duct, 
and  proved  successful.  Since  then  the  probe  was  used  for  some  time, 
and  finally  a  style  was  left  in  position. 

duction  of  a  syringe,  preparatory  to  an  operation  for 
cataract,  for  instance.  In  most  cases,  however,  epiphora 
is  present  from  the  beginning  and  is  soon  followed  by 
conjunctivitis  and  blepharitis.  The  patient  wakes  up  in 
the  morning  to  find  his  eyelids  glued  together ;  the  eye 
grows  more  and  more  sensitive  to  smoke  and  dust,  and 
conjunctival  congestion  occasionally  makes  its  appearance. 
The  itching  and  burning  of  the  inflamed  palpebral  mar- 
gins from  eczema  cause  the  patient  intense  annoyance,  and 
deformity  sometimes  results.  If  the  cornea  is  abraded  in 
the  slightest  degree  and  the  lachrymal  sac  contains  infec- 
tious material,  hypopyon-keratitis  may  develop  and  threaten 
the  patient's  eyesight.  This  happens  because  as  soon  as 
the  normal  outflow  of  the  lachrymal  fluid  is  interfered 
with,  the  pathogenic  germs  readily  rind  their  way  into  the 
conjunctival  sac  and  set  up  suppuration. 

The  active  interchange  of  germs  which  has  been  ex- 

DO 

perimentally  proven  to  take  place  between  the  conjunctiva 
and  the  palpebral  margin  explains  why  the  process  so 
frequently  extends  to  the  lids,  which,  in  addition,  offer 
many  snug  recesses  for  the  growth  of  bacteria  in  their 
numerous  glands  and  gland-ducts.  It  may  be  that  the 
growth  of  the  microorganisms  is  further  facilitated  by  the 
constant  irrigation  of  the  parts.  Many  patients  arc  driven 
to  consult  the  surgeon  by  intense  inflammation  of  the  lach- 
rymal sac  and  its  content-. 


Tab.     2. 


0 


A 


Lith..' 


DISEASES  OF  THE  LACHRYMAL  APPARATUS.     83 

By  some  process  which  is  not  well  understood  the  in- 
fectious material  finds  its  way  from  the  lachrymal  sac  into 
the  surrounding  tissues  and  sets  up  an  intense  phlegmonous 
inflammation  resembling  erysipelas,  for  which  it  is  some- 
times mistaken.  The  skin  is  very  much  inflamed,  in  places 
edematous  (on  the  lids),  and  very  tender  to  the  touch  (see 
Plates  1  and  2) ;  but  the  lachrymal  sac  can  be  distinctly 
felt  at  the  center  of  the  inflammatory  area  ;  and  as  the 
disease  progresses,  the  lachrymal  abscess  ruptures  and  a 
purulent  secretion  is  discharged.  Sometimes  the  abscess 
points  from  1  to  2  cm.  below  the  internal  palpebral  liga- 
ment, instead  of  at  the  position  of  the  sac.  This  so-called 
dacryocystitis  nearly  always  involves  the  surrounding 
tissues  as  well  as  the  sac  itself;  the  permeability  of  the 
lachrymonasal  duct  may  persist  in  spite  of  the  inflam- 
matory process,  the  intensity  of  which  depends  more  on 
the  presence  of  infectious  material  and  its  entrance  into 
the  surrounding  tissue,  than  on  the  degree  of  stricture, 
although  the  condition  is  always  preceded  by  more  or  less 
epiphora  and  obstruction  of  the  duct. 

If,  as  is  usually,  but  not  invariably,  the  case,  the  abscess 
ruptures  through  the  skin  (Plate  2),  a  lachrymal  fistula 
may  be  formed  (Plate  3).  Fortunately  this  is  a  compara- 
tively rare  occurrence,  from  which  it  may  be  argued  that 
the  accumulation  of  pus  is  probably  more  marked  in  the 
tissues  surrounding  the  sac  than  in  the  sac  itself. 

Quite  often  the  fistulous  opening  in  the  abscess,  after 
discharging  pus  for  a  time,  closes  of  its  own  accord  and 
the  inflammation  disappears  without  leaving  a  trace.  If 
a  lachrymal  fistula  is  formed,  it  usually  persists  as  a  very 
fine  opening  which  eventually  exudes  pure  lachrymal  fluid 
(Plate  3).  If  the  condition  has  lasted  a  long  time,  chronic 
distention  of  the  lachrymal  sac  (ectasia)  is  sometimes  as- 
sociated with  the  fistula.  [Lachrymal  fistula  may  be  mis- 
taken for  a  buccal  fistula  below  the  margin  of  the  orbit. 
—Ed.] 

Ectasia  of  the  lachrymal  sac  (also  called  mucocele, 
lachrymal  tumor)  may  develop  in  the  later  stages  of  the 


84  EXTERNAL   DISEASES  OF  THE  EYE. 

Plate  3. 

Lachrymal  Fistula  on  the  Right  Side ;  Ectasia  of  the  Lachrymal 
Sac  on  the  Left ;  Bilateral  Epicanthus.— A  tear-drop  is  seen  at  the  open- 
in?  of  the  fistula  on  the  right.  On  the  left  side  the  fistulous  opening 
does  not  extend  as  far  as  the  sac.  The  right  eye  shows  some  ciliary 
congestion,  due  to  a  slight  degree  of  keratitis  (not  visible  in  the  picture). 
Patient,  a  man,  29  years  old,  has  been  troubled  with  watering  of  the 
eyes  since  his  thirteenth  year.  In  1884  he  was  admitted  to  the  clinic  for 
dacryocystitis  on  the  left  side:  the  sac  was  incised  and  a  probe  passed, 
but  the  flow  of  pus  could  not  be  arrested.  At  the  time  a  scar  was  no- 
ticed on  the  right,  side,  where  he  had  been  treated  for  dacryocystitis 
before,  in  some  other  clinic.  At  present,  impermeable  stricture  of  the 
nasal  duct  on  both  sides.  On  June  12,  1897,  both  lachrymal  sacs  were 
extirpated. 


process,  with  or  without  the  formation  of  a  fistula.  It  is 
at  once  recognized  by  noting  that  the  normal  depression 
at  the  nasal  side  of  the  inner  canthus  has  disappeared  or 
has  given  place  to  more  or  less  prominence  (Plate  3),  and 
by  the  absence  of  inflammation  in  the  skin.  Pressure 
upon  the  swollen  sac  expresses  the  contents,  consisting  of 
viscid,  glairy  mucus  or  a  mucopurulent  mixture,  through 
the  canaliculi  or  into  the  nose  ;  many  patients  themselves 
discover  this  method  of  obtaining  relief.  There  is  always 
danger  that  the  ectasia  may  turn  into  a  dacryocystitis. 

When  the  accumulation  of  mucopus  in  the  lachrymal  sac 
is  very  great,  dacryocystitis  blewnvrhodca  results.  This  is 
really  nothing  but  the  result  of  an  active  purulent  catarrh 
of  the  mucous  membrane  of  the  lachrymal  sac.  It  often 
leads  to  inflammation  of  the  conjunctival  sac,  the  eyelids, 
and  possibly  even  of  the  cornea,  not  to  mention  the  lach- 
rymal sac  itself  and  its  surroundings.  The  catarrhal  se- 
cretion is  mucous  or  purulent,  depending  on  the  kind  of 
microorganisms  present  in  the  sac. 

A  catarrhal  condition  once  established  in  the  lachrymal 
sac,  even  though  the  secretion  be  only  mucous  and  the 
nasal  duct  not  obstructed,  epiphora  still  persists  because 
the  opening  from  the  sac  into  the  duct  is  stopped  up  with 
mucus. 


DISEASES  (JE  TUE  LACHRYMAL  APPARATUS.     85 

Diagnosis. — In  the  diagnosis  the  following  points  must 
be  borne  in  mind  : 

Simple  epiphora  may  be  due  to  a  nervous  disturbance  or 
to  abnormal  irritability  of  the  nasal  mucous  membrane 
[and  to  refractive  error  and  insufficiency  of  convergence  or 
to  exophora. — Ed.]. 

An  abnormal  accumulation  of  fluid  in  the  lachrymal 
sac  is  detected  by  pressing  on  the  sac  with  the  finger  in 
an  outward  direction,  from  the  nose  toward  the  eye. 

In  order  to  ascertain  whether  the  epiphora  is  caused  by 
a  stricture  in  the  nasal  duct,  a  few  drops  of  liquid  are  in- 
jected into  the  lower  canaliculus.  The  lower  canaliculus 
is  chosen  because  it  is  somewhat  wider  than  the  upper  and 
admits  the  nozzle  of  the  syringe  more  easily.  Sometimes 
the  canaliculus  has  to  be  dilated  with  a  blunt  probe  (or  a 
straightened  hairpin)  before  the  syringe  can  be  intro- 
duced. The  nozzle  of  the  syringe  should  not  be  larger 
than  that  of  an  Anel  syringe,  or  about  0.7  mm.  in  diame- 
ter. A  Pravaz  syringe,  made  entirely  of  glass,  including 
the  nozzle,  and  holding  2  grams,  is  the  best  for  the  pur- 
pose. I  consider  the  use  of  an  ordinary  syringe,  whether 
the  piston  be  made  of  leather  or  asbestos,  inadmissible, 
even  for  the  nasal  duct,  on  account  of  the  extreme  diffi- 
culty of  sterilizing  it  and  the  consequent  danger  of  infect- 
ing the  canal.  As  a  rule,  the  same  syringe  is  used  for 
everybody,  whether  the  stenosis  is  aseptic  or  not. 

As  the  injection  of  a  neutral  fluid  (0.8  per  cent,  saline 
solution)  is  practically  painless,  it  may  be  performed  in  all 
cases  without  risk  of  deterring  the  patient  from  continu- 
ing the  treatment,  as  frequently  happens  if  a  probe  is 
introduced  for  purposes  of  diagnosis. 

If  the  fluid  is  slowly  injected  into  the  lower  canaliculus 
in  this  way,  while  the  head  is  bent  slightly  forward,  it  will 
pass  out  through  the  corresponding  nostril,  if  the  duct  is 
patulous.  If  the  patient  is  lying  down,  as  is  the  case 
sometimes  in  the  examination  of  children,  the  liquid 
trickles  into  the  throat  and  the  act  of  swallowing  an- 
nounces the  permeability  of  the  duct.     If  the  lumen  is 


86  EXTERNAL    DISEASES  (JE  THE  EYE. 

only  partially  occluded,  part  of  the  liquid  flows  back 
through  the  upper  canaliculus  ;  if  occlusion  is  complete, 
the  entire  dose  is  forced  out  in  a  tine  stream. 

In  the  diagnosis  of  phlegmonous  inflammation  it  is  to 
be  remembered  that  two  other  diseases  present  similar 
clinical  pictures  : 

1.  Furuncle  is  not  uncommon  in  the  region  of  the  lach- 
rymal sac,  and  is  readily  distinguished  by  the  fact  that  it 
is  never  preceded  by  epiphora,  and  by  the  permeability 
of  the  nasal  duct,  although  some  difficulty  may  be  expe- 
rienced in  introducing  the  syringe  on  account  of  swelling 
about  the  punctum  lachrymale. 

2.  Alveolar  abscess  may  very  closely  simulate  a  dacryo- 
cystitis. Suppuration  at  the  root  of  a  tooth,  especially  the 
upper  canine,  sometimes  produces  an  abscess  in  the  region 
of  the  lachrymal  sac,  which  may  rupture  in  the  same  spot 
as  a  true  lachrymal  abscess.  If  an  alveolar  abscess  exists, 
the  upper  alveolar  border  on  the  corresponding  side  is 
swollen  and  tender  to  the  touch.  [A  track  of  suppura- 
tion leading  to  the  anterior  frontal  or  ethmoidal  cells  and 
opening  just  above  the  inner  canthal  ligament  may  be 
mistaken  for  chronic  lachrymonasal  disease. — Ed.] 

From  erysipelas  the  affection  is  easily  distinguished  if 
the  tenderness  on  pressure  and  swelling  of  the  lachrymal 
sac  are  considered. 

The  differential  diagnosis  from  tubercular  or  syphilitic 
inflammatory  processes  in  the  bones  about  the  sac  and 
nasal  duct  is  somewhat  more  difficult.  The  general  habit 
must  be  taken  into  account,  glandular  swelling  at  the 
maxillary  angle  looked  for,  and  the  condition  of  the  bone 
ascertained  by  means  of  a  sound.  If  it  is  learnt  that  a 
probe  has  already  been  introduced,  especially  during  the 
inflammatory  stage  of  the  process,  the  possibility  of  injury 
to  the  bone  must  be  considered.  The  bone  does  not 
become  inflamed  spontaneously  in  simple  stenosis,  even 
when   followed  by  dacryocystitis. 

Finally,  we  may  mention  that  carcinoma  and  sarcoma 
of  the  upper  maxillary  bone  sometimes  encroach  on  the 


DISEASES  OF  THE  LACHRYMAL   APPARATUS.     87 

region  of  the  lachrymal  sac  and  produce  a  swelling  which 
bears  some  resemblance  to  a  phlegmon.  The  fatal  error 
of  mistaking  a  malignant  growth  for  an  affection  of  the 
lachrymal  sac  can  be  avoided  by  noting  the  diffuse  swell- 
ing below  the  sac  and  the  permeability  of  the  nasal  duct, 
and  by  observing  that  there  is  less  sensitiveness  to  press- 
ure than  in  phlegmonous  affections.  [A  cyst  in  front  of 
the  lachrymal  sac  (prelachrymal  cyst)  or  a  solid  growth  in 
the  same  region  may  simulate  dacryocystitis.  Prelach- 
rymal abscess  also  occurs,  and  may  result  in  a  fistula  in 
front  of,  but  not  communicating  with,  the  lachrymal  sac. 
—Ed.] 

A  distended  lachrymal  sac,  without  inflammation  (Plate 
3),  is  sometimes  mistaken  for  a  dermoid  cyst  of  the  orbit 
(Plate  21  and  Fig.  C)  or  an  osteoma  of  the  ethmoid  bone 
(Fig.  D).  We  shall  return  to  this  subject  in  the  section 
devoted  to  diseases  of  the  orbit. 

Prognosis. — The  prognosis  in  dacryostenosis  is  always 
grave,  as  even  apparently  mild  cases  often  refuse  to  heal. 
Not  that  simple  epiphora  or  the  associated  conjunctivitis 
and  blepharitis,  troublesome  though  they  be,  are  to  be 
feared  ;  the  gravity  of  the  disease  lies  in  the  danger  to  the 
cornea  and  hence  to  the  eyesight.  In  three-fourths  of  all 
the  cases  of  hypopyon-keratitis,  which  works  such  havoc 
in  the  entire  visual  apparatus,  the  corneal  infection  is  pri- 
marily caused  by  an  obstruction  in  the  lachrymonasal 
canal. 

The  prospect  of  recovery  is  brightest  when  the  proper 
treatment  has  been  applied  from  the  beginning  of  the 
malady  and  there  are  no  false  passages  made  by  previous 
unskilful  use  of  the  probe.  Under  the  most  skilful  treat- 
ment the  result  will  depend  on  the  duration  of  the  disease, 
the  condition  of  the  contents  of  the  sac,  and  the  number 
and  permeability  of  the  strictures.  If  the  sac  has  once 
lost  its  elasticity  through  excessive  distention,  there  is  small 
hope  of  checking  the  epiphora,  even  if  the  nasal  duct  is 
clear,  for  the  draining-mechanism  is  irremediably  injured. 
A  normal  sac  acts  like  a  pump  by  forcing  the  fluid  into 


88  EXTERNAL    DISEASES  OF  THE  EYE. 

the  lachrymonasal  duct;  its  anterior  wall  is  drawn  for- 
ward during  closure  of  the  lid  by  the  action  of  the  orbicu- 
laris palpebrarum,  to  which  the  internal  lateral  ligament 
is  attached,  and  when  the  muscle  relaxes  the  wall  returns 
to  its  original  position  by  virtue  of  its  own  elasticity,  ex- 
pressing  the  contents  of  the  sac  into  the  canal.  This 
maneuver  is.impossihle  when  the  anterior  wall  is  perma- 
nently distended. 

The  prognosis  is  on  the  whole  favorable  in  certain  cases 
of  obstruction  in  infants,  which  are  due  to  deficient  com- 
munication between  the  lachrymal  canal  and  the  nasal  duct, 
and  disappear  when  continuity  is  established.  The  anom- 
aly usually  disappears  of  its  own  accord  in  a  few  weeks, 
even  when  a  considerable  degree  of  purulent  catarrh  has 
developed  in  the  lachrymal  sac,  provided  the  condition  is 
not  aggravated  by  the  introduction  of  a  probe. 

Treatment. — The  treatment  of  the  diseases  of  the  lach- 
rvmal  apparatus  that  have  been  described  has  two  main 
objects  :  1 .  .Removal  of  the  obstruction  in  the  duct ;  2. 
Removal  of  the  germs  which  cause  the  morbid  secretion  in 
the  lachrymal  passages. 

In  many  cases  a  cure  is  effected  by  merely  complying 
with  the  second  indication,  treatment  being  directed  solely 
against  the  catarrh  of  the  sac  and  duct.  There  are  cases 
in  which  the  permeability  of  the  duct  is  not  entirely  lost, 
and  the  obstruction  produced  by  swelling  and  accumula- 
tions of  mucus  is  only  temporary.  In  such  cases — they 
are  usually  of  recent  origin — simple  irrigation  with  an 
antiseptic  fluid  answers  every  purpose,  as  a  rule.  From  5 
to  10  c.c.  of  a  disinfectant  or  astringent  solution  are  in- 
jected with  a  so-called  glass  syringe  every  day,  or  every 
few  days.  A  1  :  5000  solution  of  mercuric  chlorid  (even 
1  :  1000  is  very  well  borne)  is  recommended  as  a  disin- 
fectant ;  for  an  astringent,  a  1  per  cent,  solution  of  silver 
nitrate  or  a  weak  zinc  solution  is  used. 

In  every  case  the  catarrh  and  swelling  in  the  nasal 
cavities  must  receive  appropriate  treatment  (nasal  douche, 
cauterization,  etc.).      I  have  seen  cases  of  epiphora  perma- 


DISEASES  OF  THE  LACHRYMAL  APPARATUS.     89 

nently  cured  by  cauterization  in  the  nose,  which  had 
stubbornly  resisted  treatment  with  probes. 

If  the  obstruction  is  due  to  syphilitic  processes  in  the 
nose,  ulcerations,  etc.,  general  antisyphilitic  treatment  mtist 
be  inaugurated  at  once. 

The  injections  should  be  kept  up  for  some  time,  even  if 
the  fluid  at  first  fails  to  pass  into  the  nose,  as  a  few  repeti- 
tions of  the  procedure  sometimes  suffice  to  remove  the  ob- 
struction. The  lachrymal  sac  must  always  be  thoroughly 
washed  at  the  very  outset,  especially  if  a  probe  is  to  be 
introduced  into  the  canal  for  the  purpose  of  removing  a 
stricture,  in  order  to  avoid  aggravating  the  condition  by 
scattering  the  germs  contained  in  the  sac  when  the  probe 
is  passed. 

In  many  cases  the  use  of  probes  to  remove  the  strictures 
is  unavoidable.  But  in  my  opinion  (other  specialists  may 
differ  with  me  on  this  point)  the  use  of  a  probe  is  to  be 
recommended  only  in  recent  cases,  where  it  can  be  intro- 
duced without  much  difficulty.  If  the  strictures  are  nu- 
merous and  offer  so  much  resistance  that  a  considerable 
effort  is  needed  to  effect  an  entrance,  especially  if  the  sac 
is  already  distended,  it  is  better  to  spare  the  patients  the 
hardship  of  the  procedure,  which  even  cocain  cannot 
render  painless.  Their  description  of  the  "  horrors  "  of 
the  operation  may  deter  many  others  from  subjecting 
themselves  to  the  treatment,  who  then  put  off  the  dreaded 
interview  with  the  surgeon  until  driven  to  it  by  the  very 
complications  which  make  the  treatment  hopeless.  If 
some  permeability  still  exists,  and  a  few  drops  of  a  5  per 
cent,  solution  of  cocain  can  be  injected  into  the  duct,  the 
introduction  of  a  probe  is  not  very  painful,  and  its  use  in 
such  cases  is  to  be  recommended ;  but  if  the  stricture  is 
impermeable,  cocain  is  of  little  use,  since  it  foils  to  reach 
the  desired  spot. 

The  following  suggestions,  based  on  a  large  experience 
in  the  use  of  the  probe,  may  not  be  unwelcome  : 

It  is  much  better  to  introduce  the  probe  through  the 
upper  canaliculus,  because,  when  the  instrument  is  raised 


90  EXTERNAL   DISEASES  OF  THE  EYE. 

to  the  vortical  position,  as  it  must  be  in  order  to  glide  into 
the  duct,  the  distortion  is  less  severe  than  in  the  lower 
canaliculis.  This  distortion  sometimes  has  the  disagree- 
able cflcct  of  obliterating  the  opening  .of  the  canaliculus 
into  the  sac,  making  it  absolutely  impossible  to  pass  the 
probe  into  the  sac;  and  when  afterward  the  upper  canali- 
culus  i-  incised  in  order  to  continue  the  treatment,  its 
opening  i-  also  found  to  be  obliterated,  or  soon  becomes 
so.  The  upper  canaliculus  is  not  much  harder  to  split 
than  the  lower  one.  If  the  operator  experiences  the  least 
difficulty  in  this  part  of  the  operation,  he  would  better  give 
up  the  treatment  altogether;  for  the  proper  introduction 
of  a  probe  is  a  far  more  delicate  matter,  and  should  only 
be  attempted  by  a  practised  hand,  or  it  does  more  harm 
than  good.  In  my  opinion  the  introduction  of  a  probe 
requires  the  skill  of  a  specialist  and  is  quite  as  difficult  as 
any  of  the  larger  operations  on  the  eye. 

The  maneuver  will  undoubtedly  be  attended  with  less 
pain  and  better  results,  if  a  few  days  are  allowed  to  elapse 
after  the  slitting  of  the  canaliculus,  the  incision  being  pre- 
vented from  healing.  The  following  rules  must  not  be 
neglected  on  any  account  :  The  probe  used  at  the  first  trial 
should  not  be  smaller  than  Bowman's  Xo.  3  or  4  ;  these 
two  sizes,  in  fact,  suffice  for  the  entire  treatment.  Before 
raising  the  instrument  to  the  vertical  position,  preparatory 
to  pushing  it  into  the  duct,  the  operator  should  make  sure 
that  the  point  is  in  contact  with  the  anterior  wall  of  the 
sac ;  he  determines  this  by  the  increased  resistance  of  the 
bone.  Strong  pressure  should  never  be  used.  When 
further  advance  becomes  impossible,  the  instrument  should 
be  left  in  place  a  quarter  of  an  hour,  and  further  attempts 
postponed  until  the  next  stance,  two  or  three  days  later. 
In  this  way  it  is  often  possible  to  gain  a  little  ground  at 
each  successive  trial,  without  using  undue  force,  until 
finally  permeability  is  established  at  the  third  or  fourth 
\ risit.  To  make  sure  that  the  probe  has  really  entered  the 
nose,  a  few  drops  of  liquid  are  then  injected  with  a 
de  Wecker's  cannula-syringe,  with  which  the  canal  should 


DISEASES  OF  THE  LACHRYMAL  APPARATUS.     91 

be  irrigated  at  every  subsequent  introduction  of  the  probe. 
The  syringe  is  provided  with  a  bulb,  and  in  using  it 
the  contents  (1  :  5000  mercuric  chloride)  are  gradually 
squeezed  out  as  the  syringe  is  withdrawn.  If  the  probe 
cannot  be  passed  or  withdrawn  without  using  force,  it  is 
better,  in  my  opinion,  to  abandon  the  treatment  with 
probes,  which,  it  is  true,  is  quite  feasible,  but  mostly  does 
not  furnish  permanent  cures,  because  the  strictures  con- 
stantly form  anew  and  the  hardships  of  the  treatment  are 
out  of  all  proportion  to  the  results  obtained.  If,  after  one 
or  two  trials,  the  liquid  injected  with  the  syringe  pre- 
paratory to  another  attempt  with  the  probe  fails  to  pass 
into  the  nose,  the  treatment  with  sounds  is  best  abandoned. 
Whether  self-retaining  sounds  or  styles  will  then  furnish 
better  results  remains  to  be  seen.  I  have  never  seen  any 
permanent  good  results  in  such  cases;  the  original  state 
of  affairs  never  failed  to  return  after  their  removal. 

If  the  lachrymal  sac  is  the  source  of  the  secretion  in 
these  old  cases,  it  is  best  to  extirpate  it.  If  it  contains 
but  little  secretion,  it  may  be  cleansed  as  well  as  possible 
by  repeated  injections  and  then  disinfected,  after  which 
the  canaliculi  are  to  be  closed  by  electrolysis  (with  a 
platinum  wire). 

If  the  sac  is  much  distended,  extirpation  is  indicated  at 
once,  as  in  that  case  even  permeability  of  the  duct,  if  it 
could  be  established,  would  not  check  the  excessive  flow 
nor  obviate  the  danger  to  the  cornea. 

For  new-born  infants  the  treatment  should  be  limited  to 
regular  evacuation  of  the  sac  by  pressure  with  the  finger 
until  communication  with  the  nose  is  established ;  this 
may  take  several  weeks.  In  addition  a  J  per  cent,  zinc 
solution  is  dropped  into  the  eye  once  a  day,  for  the  pur- 
posing of  controlling  the  conjunctival  catarrh. 

I  am  aware  that  my  views  on  the  treatment  of  eye-diseases  differ 
from  those  usually  advanced,  particularly  in  the  limited  field  accorded  to 
the  use  of  prohes.  These  views  are  the  result  of  twenty  years'  careful 
observation  of  patients  and  a  study  of  their  subsequent  history.  Be- 
cause a  patient  has  stopped  coming  for  treatment  is  no  reason  to  assume 
that  he  is  cured.     In  recent  cases  the  passing  of  probes,  if  performed  with 


92  EXTERNAL  DISEASES  OE  THE  EYE. 

the  proper  technic  and  as  gently  as  possible,  is  often  followed  by  good, 
permanent  results.  It  is  for  old  eases  that  I  wish  to  combat  the  routine 
application  of  this  therapeutic  method.  One  of  my  patients,  on  whom 
I  performed  extirpation  of  the  sac  on  both  sides,  later  had  a  probe  passed 
bya  colleague  who  knew  nothing  of  the  operation.  The  patient  had 
consulted  him  for  a  different  eye-trouble,  and  as  the  eye,  of  course, 
watered  a  good  deal,  a  probe  was  immediately  introduced  and  forced 
through  in  spite  of  the  resistance  encountered. 

[While  the  Editor  agrees  with  the  author  as  to  the 
necessity  of  avoiding  the  indiscriminate  use  of  probes,  as 
to  the  value  of  antiseptic  irrigation  of  the  lachrymonasal 
canal  and  the  paramount  importance  of  intranasal  treat- 
ment, he  regards  his  views  on  lachrymal  treatment  in 
general  as  too  pessimistic.  It  should  be  remembered  that 
distinguished  authorities — e.  g.,  Theobald  and  Snell — re- 
gard many  failures  to  cure  lachrymal  disease  as  due  to 
inadequate  size  of  the  probes,  and  advocate  probes  3-4 
mm.  in  diameter.] 


DISEASES  OF  THE  EYELIDS, 
i.  Inflammations. 

The  skin  of  the  eyelids  is  subject  to  the  same  diseases 
as  the  skin  covering  the  rest  of  the  body.  The  eyelids 
alone  may  be  affected,  or  the  eye-affection  may  simply 
form  part  of  a  general  process  involving  other  portion-  <»f 
the  body.  Acute  diseases,  such  as  erysipelas,  herpes 
zoster,  variola,  furuncle,  anthrax,  etc.,  are  met  with,  as 
well  as  chronic  processes,  among  which  eczema  in  it^ 
various  forms  and  seborrhea  deserve  special  mention. 

Erysipelas  and  herpes  poster  of  the  lids  are  occa- 
sionally mistaken  one  for  the  other;  a  careful  inspection, 
however,  at  onee  reveals  the  real  nature  of  the  disease. 
In  herpes  zoster  the  inflamed  area  is  confined  to  one  side 
of  the  face  (Plate  20),  because  the  skin-lesion  is  caused  by 
disease  of  the  trigeminus,  and  therefore  corresponds  to  the 
area  supplied  by  that  nerve.  The  first  branch  i-  most  fre- 
quently attacked,  the  second  much  less  frequently,  and  the 


DISEASES  OF  THE  EYELIDS.  93 

third  very  rarely,  if  ever.  If  the  first  branch  of  the  nerve 
is  diseased,  the  eruption  appears  on  the  forehead,  as  far  as 
the  median  line,  on  the  upper  lid  and  its  immediate  sur- 
roundings, on  the  side  of  the  nose  (corresponding  to  the 
distribution  of  the  nasociliary  nerve),  and  on  that  part  of 
the  hairy  scalp  supplied  by  the  nerve.  In  erysipelas  the 
eruption  is,  of  course,  not  confined  within  such  limits. 
Moreover,  the  vesicles  in  erysipelas  are  large,  while  in 
herpes  zoster  they  are  small  and  coalesce  in  patches,  cor- 
responding to  the  terminal  distributions  of  the  nerves. 
They  at  first  contain  a  clear  fluid  which  later  becomes 
purulent,  and  in  a  short  time  they  dry  up  and  form  scabs. 
From  admixture  with  hemoglobin  the  scabs  are  usually  of 
a  dark-brown  or  black  color  (Plate  20),  giving  the  disease 
its  characteristic  appearance  which  lasts  for  several  days. 
The  edges  of  these  scabs  are  indented,  in  accordance  with 
the  irregular  patches  of  vesicles  from  which  they  are 
formed,  and  have  been  described  as  resembling  a  geograph- 
ical map.  The  same  irregularity  of  outline  character- 
izes the  scars,  which  are  slightly  depressed  (at  first  red, 
later  becoming  white),  and  remain  visible  for  years,  show- 
ing that  the  corium  is  involved  in  the  vesicular  eruption, 
which  is  not  the  case  in  erysipelas  or  herpes  febrilis. 

Herpes  zoster  ophthalmicus,  like  herpes  zoster  in  other 
parts  of  the  body  (e.  g.,  in  the  area  supplied  by  the  inter- 
costal nerves,  so-called  "  rose-girdle  "),  is  further  charac- 
terized by  the  occurrence  of  severe  neuralgic  pains,  both 
before  and  during  the  eruptive  stage,  and  even  during  the 
period  of  convalescence,  many  patients  complaining  of 
pain  in  the  region  supplied  by  the  affected  nerve  for 
weeks  after  subsidence  of  the  eruption.  In  many  cases, 
on  the  other  hand,  there  is  anesthesia  of  the  affected  area 
during  convalescence.  The  morbid  process  quite  fre- 
quently involves  the  cornea  ;  we  shall  speak  of  this  again 
in  the  section  devoted  to  inflammations  of  the  cornea. 

The  treatment  of  the  skin-lesion  in  herpes  zoster  con- 
sists in  fostering  the  healing  of  the  scabs ;  for  this  pur- 
pose either  a  dusting-powder,  consisting  of  white  zinc  oxid 


94  IW'TERXAL   DISEASES  OF  THE  EYE. 

and  rice-starch,  or  vaselin,  may  be  used.  For  the  relief 
of  the  neuralgia  the  uninterrupted  current  of  electricity  has 
been  advocated. 

Eczema  occupies  a  prominent  place  among  diseases  of 
the  eyelids. 

The  dry  form,  eczema  squamosum,  attacks  the  surface  of 
the  lids  and  contiguous  areas.  The  skin  is  rough  and 
somewhat  inflamed  ;  the  patient  complains  of  itching.  A 
speedy  cure  is  usually  effected  with  oil  of  cade  (which 
must  not  be  allowed  to  enter  the  eye)  or  with  5  per  cent, 
ichthvol  ointment. 

The  moist  or  vesicular  variety  is  much  more  common, 
both  on  the  surface  of  the  lids  and  particularly  on  the 
ciliary  margin,  where  it  leads  to  the  disease  called  blepha- 
ritis ulcerosa.  Eczema  on  the  surface  of  the  lids  is  usually 
associated  with  the  same  disease  on  adjoining  areas,  the 
hairy  scalp,  the  ears,  etc. ;  the  treatment  consists  in  clean- 
liness and  the  application  of  Hebra's  ointment. 

Blepharitis  eczemaiosa  often  occurs  in  combination  with 
this  process,  although  it  also  occurs  independently,  and  in 
that  case  is  apt  to  be  very  refractory.  It  is  also  observed 
secondary  to  conjunctival  catarrh  or  to  keratitis,  from 
maceration  of  the  lids  by  the  conjunctival  secretion  or  the 
excessive  flow  of  tears;  and,  finally,  it  is  met  with  as  a 
concomitant  to  a  form  of  eczema  which,  as  we  shall  see 
later,  frequently  attacks  the  conjunctiva  and  cornea  in 
scrofulous  and  anemic  subjects.  Children  are  particularly 
liable  to  this  trilogy,  and  frequently  afford  us  an  oppor- 
tunity of  observing  the  simultaneous  occurrence  of  the 
process  on  the  lids,  the  conjunctiva,  and  the  cornea,  asso- 
ciated often  with  eczema  of  the  nose,  mouth,  ears,  and 
hairy  scalp.  It  would  appear,  therefore,  as  Horner  no 
doubt  correctly  thinks,  that  clinically  at  least  there  is  a 
connection  between  these  three  different  manifestations  of 
eczema  (blepharitis,  conjunctivitis,  and  keratitis  eczenia- 
tosa),  although  we  still  lack  anatomic  or  baeteriologic 
proof  of  their  identity.  Upon  closer  inspection  we  ob- 
serve that  the  individual  vesicles  possess  a  circular  outline 


DISEASES  OE  THE   EYELIDS.  95 

and  soon  produce  ulcers  of  varying  depth,  which  on  the 
cutaneous  surface  of  the  lids  become  covered  with  scabs, 
while,  of  course,  on  the  conjunctival  mucous  membrane 
and  on  the  cornea  no  such  scab-formation  can  take  place. 

Marginal  eczema  presents  various  clinical  pictures,  ac- 
cording to  the  type  and  intensity  of  the  process.  Solitary, 
Hat,  round  pustules,  of  a  yellowish  color,  may  be  scattered 
among  the  tufts  of  matted  cilia,  or  pierced  by  a  single 
cilium  (Plate  4,  b) ;  or  the  yellow  pustules  are  replaced  by 
the  well-known  eczema-scabs,  removal  of  which  with  the 
cilium-foreeps  reveals  the  small  round  ulcer  beneath,  with 
the  discharge  of  a  few  drops  of  thin  pus.  The  ulcers 
sometimes  form  a  continuous  series,  or  several  of  them 
coalesce.  If  they  penetrate  to  the  deeper  layers  of  the 
corium,  as  a  result  of  suppuration,  the  roots  of  the  cilia 
are  destroyed  and  the  characteristic  yap*  in  the  eyelashes 
appear  (Plates  4,  b  ;  6,  a  ;  and  23,  b).  In  severe  types  of 
pustular  eczema,  such  as  occur  in  children  of  marked  scrof- 
ulous habit  or  after  measles,  the  four  lids  may  become 
involved.  The  surface  of  the  lids  becomes  edematous, 
the  edges  thickened  and  inflamed,  and  the  entire  palpebral 
margin  is  covered  with  crusts,  through  which  the  tufts  of 
matted  cilia  are  seen  projecting.  On  careful  inspection  of 
the  upper  lid  small  pustules,  still  covered  with  epidermis, 
may  be  seen  underneath  the  crusts.  When  the  latter  are 
removed,  part  of  the  cilia  usually  come  away  with  them, 
exposing  the  moist  and  bleeding  surface  of  the  palpebral 
margin  covered  with  deep  ulcers. 

If  the  inflammatory  process  is  protracted,  the  cilia  drop 
out  in  ever-increasing  numbers  or  become  misplaced  in- 
ward by  the  cicatricial  contractions  which  follow  the 
healing  of  the  ulcers,  and  cause  abrasions  on  the  cornea 
(trichiasis).  The  palpebral  margin  becomes  permanently 
thickened  and  a  squamous  form  of  eczema  continues  for 
some  time  to  torment  and  disfigure  the  patient.  Eventually 
either  entropion  or  ectropion  may  result  :  the  former  in 
consequence  of  the  cicatricial  contractions  on  the  inner 
surface  of  the  lid-margins ;  the  latter  on  account  of  the 


96  EXTERNAL    DISEASES   OF   THE  EYE. 

Plate  4. 

n.  Papular  Syphilide  (from  Mrapek,  Atlas  of  Syphilis  and  the  Venereal 
Diseases,  Plate  22). 

b.  Blepharitis  eczematosa,  associated  with  slight  eczematous  keratitis 
(whence  the  ciliary  congestion)  and  eczema  of  the  ear.  The  patient, 
who  had  been  suffering  for  some  time  from  inflammatory  eczema  of  the 
eyes,  had  earrings  put  in  his  ears,  with  the  soli-  result  that  the  ears  also 
became  eczematous  and  the  lohe  inflamed.  About  the  middle  of  the 
lower  lid  there  is  a  gap  in  the  lashes  from  a  previous  attack  of  eczema  : 
on  the  upper  lid  recent  eczematous  ulcers  are  seen. 


cicatrization  which  is  ultimately  brought  about  on  the 
outer  surface  by  the  incessant  maceration.  In  the  case  of 
the  lower  lid  the  development  of  ectropion  is  also  fostered 
by  the  mechanical  drawing  down  of  the  margin  when  the 
eye  is  wiped. 

The  eczema  which  follows  a  dacryostenosis  may,  in  view 
of  its  etiology,  be  classed  as  a  special  form.  Chronic  con- 
junctival catarrh  from  any  cause  usually  leads  to  the 
development  of  marginal   eczema   in   the  end. 

From  a  clinical  point  of  view  eczema  of  the  lids  should 
be  classed  with  diseases  due  to  dirt,  especially  in  children. 
A  few  chronic  cases  may  perhaps  be  explained  on  the 
theory  of  natural  predisposition.  In  other  cases  the  dis- 
ease is  fostered  by  a  debilitated  condition  of  the  organism, 
in  children  especially  by  scrofula,  anemia,  and  acute  dis- 
eases like  measles,  whooping-cough,  etc. 

The  diagnosis  in  marginal  eczema  presents  no  great 
difficulties;  the  differential  diagnosis  from  squamous 
blepharitis  or  seborrhea  of  the  lids  will  be  discussed  in 
the  section  devoted  to  that  disease.  The  prognosis  in 
acute  cases  is  correspondingly  favorable;  in  chronic 
eczema  among  adults,  which  is,  on  the  whole,  a  rarer  oc- 
currence, it  is  less  favorable. 

The  treatment  should  be  both  general  and  local,  based 
on  a  careful  consideration  of  the  etiologic  conditions. 
Scrupulous  cleanliness  and  general  supporting  remedies 
are  the  first  requisites.     The  local  treatment  is  directed 


Tab      4. 


üth.  Anst  F.  Reichhold.  Münclxerr . 


DISEASES  OF  TUE  EYELIDS.  97 

principally  toward  the  removal  of  such  causal  conditions 
as  dacryostenosis  and  conjunctival  catarrh. 

Eczema  in  contiguous  areas  must  also  he  subjected  to 
vigorous  treatment.  The  scabs  are  to  be  first  softened 
with  Hebra's  or  with  white  precipitate  ointment,  1  per 
cent,,  in  the  form  of  a  plaster,  and  then  removed.  The 
exposed  ulcers  are  then  covered  with  the  same  ointment  or 
painted  with  a  2  per  cent,  solution  of  silver  nitrate,  or 
even  touched  lightly  with  the  mitigated  stick.  The  cau- 
terization-scab must  not  be  disturbed,  and  when  it  comes 
away  of  its  own  accord  the  application  is  repeated,  and  so 
on  until  no  more  ulcers  appear. 

Children  should  have  their  eyes  bandaged  after  the 
ointment  has  been  applied,  to  prevent  rubbing  with  the 
hands.  Compresses  steeped  in  bichlorid  solution  have 
been  recommended  to  keep  the  parts  perfectly  clean,  par- 
ticularly if  eczema  of  the  cornea  is  present.  A  1  :  5000 
solution  is  used.  In  a  very  few  individuals  a  bichlorid 
dressing  induces  eczema ;  if  so,  it  is  at  once  detected  ;  in 
all  other  cases  this  form  of  wet  dressing  does  not  produce 
eczema. 

Extraction  of  the  cilia  is  to  be  recommended  only  in 
chronic  eczema  in  adults,  and  should  be  followed  by  an 
application  of  tincture  of  iodin  to  the  palpebral  margin  ; 
the  tincture  must  not  be  allowed  to  enter  the  conjunctival 
sac.  The  same  remedy  is  employed  in  all  cases  of  chronic 
thickening  and  inflammation  of  the  palpebral  margins.  If 
the  moist  form  changes  into  the  squamous  variety,  oil  of 
cade  is  substituted  for  tincture  of  iodin. 

Seborrhea  of  the  palpebral  margins  (Horner),  also 
known  as  squamous  blepharitis,  is  an  affection  which  is 
often  confounded  with  eczema.  The  differential  diagnosis 
is  not  difficult,  if  the  following  points  are  borne  in  mind  : 

Marginal  seborrhea  very  often  follows  in  the  wake  of 
similar  disease  in  the  hairy  scalp,  characterized  by  falling 
out  of  the  hair,  the  formation  of  dry  scales,  and  a  fatty 
secretion.  The  lashes  gradually  drop  out,  the  itching  be- 
comes intense,  and  the  patient  is  finally  driven  to  consult 
7 


98  EXTERNAL  DISEASES   OF  THE  EYE. 

Plate  5. 

Meibomian  or  internal  hordeolum  in  the  temporal  third  of  the  right 
upper  lid,  of  four  days'  duration.  Mild  conjunctival  catarrh  has  existed  for 
some  time,  hence  the  conjunctival  congestion.  Course:  Spontaneous 
evacuation  of  pus  through  the  conjunctiva.  Treatment  of  catarrh 
undertaken  to  prevent  recurrence  of  the  inflammatory  process  in  the  lid. 


a  doctor  when  his  e,ves  have  become  more  and  more  sen- 
sitive to  radiating  heat  and  can  no  longer  stand  the  strain 
of  continuous  use,  especially  if,  as  often  happens,  conjunc- 
tival catarrh  and  hordeolum  add  their  quota  to  his  discom- 
forts. The  inflamed  and,  in  chronic  cases,  thickened 
margins  exhibit  the  cardinal  symptom  of  the  disease: 
Scales,  appearing  either  as  a  fine  white  powder  among  the 
cilia,  or  of  a  more  pronounced  branny  character,  in  rare 
cases  mixed  with  a  fatty  secretion  to  form  larger  scabs, 
presenting  a  certain  likeness  to  the  crusts  in  eczema ;  but 
on  removal  of  the  scabs  with  the  cilium-forceps  no  ulcers 
are  found  on  the  skin,  which  is  red  and  smooth  and  cov- 
ered with  thin  epidermis.  The  cilia  also  are  characteristic 
in  this  disease  :  the  longer  the  process  has  lasted  the 
shorter,  thinner,  and  more  sparsely  distributed  will  be  the 
eyelashes,  robbing  the  eye  of  its  chief  ornament.  The 
inflamed  and  thickened  margins  take  on  a  deeper  red  at 
each  fresh  irritation  or  congestion,  and  the  eyelashes  are 
ultimately  reduced  to  a  thinly  scattered  row  of  almost  color- 
less  hairs.  In  eczema  we  have  normally  developed  cilia 
alternating  with  areas  entirely  denuded  of  hair;  in  sebor- 
rhea, on  the  contrary,  the  cilia  are  uniformly  sparse  and 
poorly  developed,  showing  that  we  have  to  deal  with  a 
skin-disease  which  directs  its  attacks  principally  against 
the  hair-follicles. 

Heredity  plays  an  important  role  in  this  form  of  blepha- 
ritis. The  disease  often  begins  in  youth,  and  many  people 
suffer  from  it  all  their  lives.  Although  we  have,  as  yet, 
no  proof  that  the  disease  is  due  to  a  microorganism,  there 
are  many  reason-  for  thinking  that  it  is  contagious. 

Diagnosis. — In  addition  to  eczema,  phthiriasis — i.  e., 


Tab. 


IflJi.Ansl  /•:  Kpuliholü.  München. 


DISEASES   OF   THE  EYELIDS.  99 

the  presence  of  lice  among  the  eyelashes — may  be  mis- 
taken for  this  affection.  The  parasites  usually  belong  to 
the  variety  phthiri us  inguinalis,  or  crab-louse;  head-lice 
rarely  attack  this  region.  The  disease  may  be  mistaken 
for  molluscum  contagiosum  (Plate  6,  b)  if  the  nodules  are 
small  and  the  examination  has  been  very  superficial. 

Prognosis. — The  disease  is  a  serious  one.  Not  only  is 
the  eye  disfigured  and  its  usefulness  impaired;  but  if  the 
cilia  are  lost,  the  conjunctival  catarrh  which  ensues  is  apt 
to  resist  all  treatment,  and  may  in  the  course  of  years  pro- 
duce ectropion,  which,  in  turn,  brings  on  disease  of  the 
cornea  and  other  more  serious  complications.  The  disease 
can  only  be  cured  in  youth.  In  later  life  the  evil  may 
be  -palliated  or  temporarily  checked  ;  but  it  recurs  as 
soon  as  the  conditions  are  favorable:  radiated  heat,  night- 
work,  etc. 

The  treatment  should  match  the  disease  in  stubborn- 
ness. Other  hairy  parts  of  the  body,  if  the  seat  of  sebor- 
rhea, must  be  treated  with  lotions  of:  Carbol,  5  percent.; 
sulph.  precip.,  2  per  cent.,  mixed  with  equal  parts  of  alco- 
hol and  eau  de  Cologne,  or  with  sulphur  ointment.  The 
eve-  must  be  thoroughly  cleansed  every  morning  with  a 
fine  linen  cloth,  after  having  been  carefully  rubbed  the 
night  before  with  an  ointment  consisting  of  turpeth  min- 
eral (basic  mercuric  sulphate),  or 

White  precipitate  (hydra  rg.  ammoniat.),  0.05 

Vaselin, 

Lanolin,  ää  5.0 

The  ointment  is  to  be  applied  immediately  before  going  to 
sleep.  Salves  which  tend  to  become  rancid  only  aggravate 
the  evil.  In  winter  the  eyes  should  be  washed  with  warm 
water.  This  treatment  must  be  prescribed  for  several 
months  from  the  very  outset.  In  chronic  cases  tincture 
of  iodin  may  be  used  with  advantage.  [An  excellent 
ointment  for  squamous  blepharitis  is  one  composed  of  3 
per  cent,  of  milk  of  sulphur  and  3  per  cent,  of  resorcin. 


100  EXTERNAL  DISEASES  OE  THE  EYE. 

Plate  6. 

a.  Eczematous  blepharitis  of  long  standing,  so  that  on  one  side 
numerous  gaps,  on  the  other  only  the  squamous  form  of  the  disease,  arc 

seen. 

b.  Molluscum  contagiosum  and  external  hordeolum  in  a  girl.  17  years 
old.  The  uniformly  small  nodules  are  most  numerous  in  the  region  of 
the  eyes ;  a  few  isolated  ones  are  also  seen  on  the  rest  of  the  face  and  on 
the  upper  part  of  the  body  ;  but  they  have  not  as  yet  spread  to  the  lower 
portions.  The  nodules  show  the  characteristic  central  opening  or  depres- 
sion. The  external  hordeolum  which  is  seen  on  the  lower  lid,  a  little  to 
the  nasal  side  of  the  center,  is  merely  an  accidental  complication. 

The  scales  should  first  be  removed  with  a  5  per  cent,  solu- 
tion of  chloral  (Gradle)  or  with  a  solution  of  sodium 
bicarbonate.  Pagen  stecher's  ointment  (yellow  oxid  of 
mercury)  is  useful  in  ulcerated  and  eczematous  bleph- 
aritis, as  is  also  aristol  ointment.  In  all  cases  of  bleph- 
aritis an  essential  part  of  the  treatment  is  the  thorough 
correction  of  any  existing  refractive  error.  This  alone 
will  suffice  to  cure  many  mild  cases. — Ed.] 

The  various  glands  in  the  lids  frequently  become  the 
seat  of  inflammation.  We  have  two  varieties  to  deal 
with  :  1.  About  600  sebaceous  glands,  which  accompany 
the  cilia  on  both  the  upper  and  the  lower  margins,  the  so- 
called  glands  of  Zeiss;  2.  The  long,  acinous  Meibomian 
glands,  which  lie  closely  packed  in  the  tarsus,  in  perpen- 
dicular lines  to  the  palpebral  margin.  They  are  prac- 
tically enlarged  sebaceous  glands,  opening  on  the  free 
border  of  the  lid  and  by  their  oily  secretion  preventing 
the  tears  overflowing. 

Hordeolum. — Suppuration  of  a  sebaceous  gland  leads 
to  the  formation  of  the  well-known  stye  or  external  horde- 
olum (Plate  6,  b,  lower  lid,  to  na^al  side  of  center) ;  while 
the  same  process  in  one  or  more  Meibomian  glands  pro- 
duces the  so-called  infernal  hordeolum,^  much  more  serious 
disturbance,  the  inflammation  being  more  extensive  and 
the  pain  proportionately  greater.  The  redness  and  swell- 
ing of  surrounding  parts  are  so  great  as  to  simulate  the 
picture  of  erysipelas  or  ophthalmic  blennorrhea.    The  lids 


Tab.     6. 


9 


6* 


1bfc**«ai5v^ 


Liih. Anst  E  Rachlwlä  München. 


DISEASES  OF  THE  EYELIDS.  101 

and  the  conjunctivae  may  be  edematous,  especially  if  the 
purulent  focus  is  situated  near  the  outer  canthus.  This  is 
easily  found  by  palpating  the  inflamed  lid,  as  it  is  ex- 
tremely painful ;  sometimes  it  corresponds  with  a  small 
yellow  pustule  on  the  margin  of  the  lid.  It  marks  the 
opening  of  the  duct  of  the  inflamed  Meibomian  gland  or 
glands.  If  the  patient  can  bear  the  discomforts  of  the 
procedure,  it  is  sometimes  possible  to  inspect  the  inner 
surface  of  the  lid  and  note  the  accumulated  pus  shining 
through  the  conjunctiva.  For  the  small  abscess  which 
forms  in  a  short  time  is  more  likely  to  rupture  through 
the  conjunctiva  than  through  the  skin.  With  the  bursting 
of  the  abscess  the  pain  and  discomfort  cease  and  the 
swelling  subsides. 

Both  the  internal  and  the  external  hordeolum,  but 
especially  the  latter,  may  recur  for  weeks  or  even  months, 
first  in  one  and  then  in  another  of  the  four  palpebral  mar- 
gins. The  process  is  fostered  by  seborrhea  and  chronic 
conjunctival  catarrh  ;  but  the  first  fundamental  condition 
is  the  presence  of  pyogen  ic  microorganisms.  I  once  had 
occasion  to  observe  how  the  introduction  into  the  con- 
junctival sac  of  a  virulent  culture  of  staphylococcus 
aureus  caused  the  occurrence  of  hordeola. 

There  is  every  justification  for  classifying  these  two 
forms  of  gland-inflammation,  as  well  as  chalazion  (to  be 
described),  under  the  head  of  aoie,  as  Horner  has  sug- 
gested. 

Neither  variety  of  hordeolum  produces  permanent  in- 
jury, and  the  treatment  is  quite  simple.  Active  poul- 
ticing with  linseed-meal  is  recommended,  both  to  alleviate 
the  suffering  and  to  shorten  the  process  by  bringing  the 
abscess  to  the  point  of  spontaneous  evacuation  or  incision. 
[Repeatedly  applied  compresses  soaked  in  hot  carbolized 
solution  or  in  hot  water  containing  33  per  cent,  of  fluid  ex- 
tract of  hamamelis  is  preferable. — Ed.]  The  knife  should 
be  used  as  soon  as  a  distinct  purulent  focus  is  seen  through 
the  conjunctiva,  the  incision  being  made  from  within,  per- 
pendicular to  the  margin. 


102  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  7. 

a.  Chalazion  on  the  upper  lid  of  a  young  man;  developed  during  the 
last  two  mouths.     Incision  from  within  and  evacuation  resulted  in  cure. 

h.  Multiple  chalazion,  on  the  right  eve  of  a  young  woman ;  developed 
gradually  during  the  last  six  months. 

,-.  The  lower  lid  of  the  same  side,  seen  from  within  Conjunctiva 
shows  proliferation  resembling  granulation.  Evacuation  from  within. 
Cure. 


To  prevent  the  recurrence  of  hordeola  I  have  found  it 
advisable  to  prescribe  a  collyrium  for  several  weeks  after 
the  subsidence  of  the  inflammation.  This  is  composed 
as  follows  :  Zinc  sulphate,  0.1  to  20.0  of  a  solution  of 
sublimate,  1  :  5000  or  1  :  10,000.  Seborrhea,  if  present, 
must  be  treated. 

From  what  has  been  said  it  is  evident  that  chalazion 
and  hordeolum  are  more  or  less  related.  In  most  cases 
the  chalazion  develops  slowly,  without  giving  rise  to  in- 
flammatory symptoms;  occasionally,  however,  its  incep- 
tion or  subsequent  course  is  attended  with  inflammation. 
The  nodule  in  the  course  of  weeks  or  months  may  attain 
tin-  size  of  a  pea  or  half  a  cherry  (Plate  7,  a)  \  quite 
frequently  it  is  multiple  (Plate  7,  b),  in  which  case  its 
favorite  seat  is  in  the  upper  lid.  The  skin  is  not  inflamed 
at  first,  and,  whether  the  growth  be  single  or  multiple, 
always  moves  with  the  shifting  of  the  swelling,  which  is 
only  movable  with  the  tarsus.  The  conjunctiva  on  the 
inner  surface  of  the  lid  is  red  and  swollen,  and  sometimes 
hypertrophied,  as  if  it  were  the  seat  of  granulations  (Plate 
7,  <■).  This  is  more  particularly  the  ease  when  the  tumor 
is  preparing  to  burst  or  has  already  done  so.  The  contents 
of  the  nodule  are  grayish  and  can  often  be  seen  through 
the  wall-.  Anatomic  examination  -hows  that  the  tumor 
is  situated  within  the  tarsus,  and  therefore  originate-  in 
one  or  more  Meibomian  glands.  The  content-  consist  of 
a  soft,  grayish-red  mass  of  granulations,  more  or  less 
liquid  in  the  center.  The  walls  of  the  tumor  are  formed 
by  the  dense  connective  tissue  of  the  tarsus.    Microscopic 


'ab.     7. 


' 


■  Wi 


8   4M- 


l.ith.  Ar  ist  F.  Reich  f  wld '.  München-. 


DISEASES  OF  THE  EYELIDS.  103 

examination  reveals  that  the  chalazion  begins  with  a  pro- 
liferation of  the  epithelium  in  the  acini  of  a  Meibomian 
gland,  the  acini  becoming  surrounded  by  an  ever-increas- 
ing inflammatory  infiltration  of  the  tarsus.  As  the 
glands  are  destroyed  the  small-cell  infiltration  increases 
and  forms  granulation-tissue,  with  a  few  giant  cells,  so 
that  the  entire  growth  comes  to  resemble  a  tubercular  pro- 
liferation, although  the  process  has  nothing  whatever  to  do 
with  tuberculosis.  On  the  contrary,  this  chronic  inflam- 
mation of  the  Meibomian  glands  is  probably  due  to  another 
bacillus,  which  I  found  in  several  cases  in  small  numbers. 
It  was  difficult  to  stain.  Perhaps  it  is  identical  with  that 
described  later  by  Devi. 

One  argument  in  support  of  the  specific  nature  of  chala- 
zion is  the  fact  that  it  is  always  preceded  by  mild,  chronic 
catarrh  of  the  conjunctiva,  and  that  the  formation  of  other 
chalazia  is  best  prevented  by  checking  the  conjunctival 
catarrh  by  means  of  the  preparation  of  zinc  referred  to  in 
connection  with  hordeolum.  "We  also  know  that  chronic 
conjunctival  catarrh  favors  the  growth  of  pathogenic  mi- 
crobes in  the  conjunctival  sac. 

( 'halazia  must  be  removed  as  soon  as  they  have  attained 
a  certain  size;  very  small  ones  need  no  treatment.  A 
large  conjunctival  incision  is  made  running  vertically  to 
the  palpebral  margin  and  the  contents  scraped  out  with  a 
curet.  The  capsule  is  allowed  to  take  care  of  itself,  so 
that  the  swelling  does  not  subside  until  one  or  two  weeks 
after  the  operation.  If  the  operation  is  properly  per- 
formed, the  tumor  will  not  recur.  If  the  growth  is  nearer 
the  skin  and  threatens  to  burst,  a  horizontal  incision  may 
be  made  through  the  skin  parallel  to  the  lid-margin  and 
the  contents  removed  in  that  way.  A  chalazion  must 
never  be  cauterized  from  the  conjunctival  side,  as  the 
resulting  cicatrization  leads  to  trichiasis  and  entropion. 
[The  conjunctival  hyperemia  induced  by  eye-strain  is  a 
constant  cause  of  chalazia  and  hordeola  ;  therefore  the 
necessity  of  correcting  the  refraction  of  the  eye  if  it  is 
anomalous. — Ed.] 


104  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  8. 

Blepharochalasis  on  Both  Sides.— The  patient  is  31  years  old  ;  other- 
wise quite  well;  no  sugar  or  albumin  in  the  urine.  The  disease  began 
eleven  years  ago;,  the  eyes  are  much  disfigured  by  the  redness  and 
swelling  of  the  lids.  Dilated  veins  are  seen  in  the  inflamed  skin.  In 
this  case,  a>  in  the  last,  there  is  a  suggestion  of  epicanthus,  the  skin  of 
the  upper  lid  being  overlapped  by  the  fold  of  epicanthus,  more  so  on  the 
right  than  on  the  left  side.  The  results  of  operative  removal  were  very 
satisfactory.  Only  a  narrow  strip  of  >kin  and  orbicularis  was  excised  ; 
the  lower  lip  of  the  wound  was  firmly  attached  to  the  upper  margin  of 
the  tarsus  by  means  of  eight  sutures. 


2.  Anomalies  in  the  Shape  and  Position  of  the  Eyelids. 

Congenital  ptosis  (Plate  9),  or  drooping  of  the  upper 
lids,  from  paralysis  or  defective  development  of  the  leva- 
tor palpebral  superioris,  is  usually  bilateral,  while  the 
acq  a  ired  form  commonly  occurs  only  on  one  side.  Ac- 
quired ptosis  often  follows  paralysis  of  the  sympathetic, 
being  directly  caused  by  paralysis  of  the  involuntary 
Müller's  muscle,  an  accessory  of  the  levator  palpebral 
The  condition  is  characterized  by  contracted  pupil  and 
vasomotor  paralysis  on  the  affected  side  of  the  face. 
Ptosis  due  to  paralysis  of  the  oculomotor  nerve  is  more 
marked  and  the  pupil  of  the  affected  eye  is  usually  dilated. 

The  congenital  anomaly  known  as  epicanthus  (Plates  3 
and  9)  consists  of  a  crescentic  fold  of  skin  which  sur- 
rounds and  partially  covers  the  internal  canthus.  The 
condition  is  normal  in  the  Mongolian  race  and  in  many 
new-born  infants  of  the  Caucasian  race,  gradually  disap- 
pearing among  the  latteras  the  bridge  of  the  nose  is  more 
fully  developed.  If  the  fold  persists  to  adult  age,  it  must 
be  removed  by  direct  excision  ;  the  practice  of  excising  an 
elliptical  piece  of  skin  from  the  bridge  of  the  nose  is 
unsatisfactory,  in   my  opinion. 

Ptosis  adiposa  (lipomatosis)  and  blepharochalasis  (Plates 
8  and  9)  are  two  congenital  anomalies  primarily  due  to 
defective  attachment  of  the  integument  to  the  upper 
margin  of  the  tarsus  and  the  tendon  of  the  levator.     The 


BS 


,  A 


DISEASES  OF  THE  EYELIDS.  105 

skin  cannot  be  raised  with  the  lid,  and  hangs  down  like  a 
pouch  over  the  palpebral  margin,  producing  a  marked 
deformity.  According  to  Fuchs,  the  skin  is  very  thin 
and  slightly  hyperemic.  The  two  anomalies  may  be  cor- 
rected by  excising  a  portion  of  the  redundant  skin  and 
attaching  it  by  means  of  sutures  to  the  upper  margin  of 
the  tarsus  (Hotz's  operation). 

The  foregoing  anomalies  are  rare  compared  with  the 
conditions  termed  ectropion  and  entropion. 

Ectropion  (also  called  eversion  of  the  lid-margin  when 
very  slight)  occurs  in  the  lower  lid  when  the  skin  and 
tarsus  become  relaxed — senile  ectropion  ;  or  in  consequence 
of  cicatricial  contraction  of  the  skin  after  traumatism — 
cicatricial  ectropion.  The  cicatricial  form  develops  in 
caries  of  the  orbital  margin,  after  burns,  scalds,  ulcera- 
tions, etc.,  or  through  the  gradual  cicatrization  attending 
the  repeated  excoriations  and  eczematous  eruptions  brought 
on  by  constant  maceration  and  wiping  of  the  eyes  in 
dacrvostenosis  and  chronic  catarrh. 

The  paralytic  form  is  produced  by  palsy  of  the  facial 
nerve  which  supplies  the  orbicularis  palpebrarum.  The 
lower  lid  only  is  everted,  the  upper  lid  being  drawn  up- 
ward by  the  preponderance  of  the  levator  and  Müller's 
muscle.  The  direct  result  is  lagophthalmos,  or  inability  to 
close  the  eye,  especially  during  sleep,  which  is  apt  to  pro- 
duce conjunctival  catarrh.  Another  important  form  of 
lagophthalmos  is  due  to  protrusion  of  the  eye  from 
tumors  of  the  orbit  and  exophthalmic  goiter. 

Spastic  ectropion  is  sometimes  met  with  in  young  per- 
sons, due  to  abnormal  contraction  of  the  orbicularis  palpe- 
brarum. It  is  corrected  by  replacement  and  a  suitable 
bandage. 

The  remaining  varieties  of  ectropion  demand  surgical 
treatment,  by  means  of  which,  above  all  things,  the  elonga- 
tion of  the  lid  that  is  often  present  must  be  corrected  by 
excising  a  wedge-shaped  portion  of  the  tarsus  and  conjunc- 
tiva (after  the  method  of  Kuhnt  or  Dimmer's  modification 
of  his  operation).     If  the  ectropion   is  slight,  Snellen's 


106  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  9. 

Blepharochalasis  in  the  Later  Stages ;  Congenital  Ptosis ;  Epican- 
thus. — The  patient,  26  years  old,  is  terribly  disfigured  by  the  malady. 
It  could  not  be  definitely  ascertained  whether  the  ptosis  was  congenital. 
The  characteristic  wrinkles  are  seen  on  the  forehead.  The  epicanthus 
is  partly  congenital  and  partly  caused  by  the  blepharochalasis;  deep, 
ugly  looking  pits  are  concealed  under  the  folds.  The  skin  of  the  upper 
lids  is  relaxed  and  hangs  down  in  folds.  In  the  upper  portion  of  the 
right  upper  lid  a  few  vertical  folds  are  seen.  The  same  swelling  of  the 
lids,  seen  in  the  preceding  case,  was  formerly  present.  The  malady 
began  spontaneously  with  swelling  and  inflammation,  when  the  patient 
was  five  years  old.  The  redness  and  swelling  gradually  disappeared  in 
his  thirteenth  year  and  gave  place  to  the  present  condition.  The 
results  of  operative  treatment  were  very  satisfactory.  A  larger  piece  of 
skin  was  cut  away  than  in  the  preceding  case,  mostly  from  the  nasal 
portion  of  the  upper  lid,  for  the  purpose  of  correcting  the  epicanthus. 
In  placing  the  sutures  the  needle  was  introduced  through  the  lower 
margin  of  the  wound,  then  through  the  upper  margin  of  the  tarsus,  and 
passed  out  through  the  tendon  of  the  levator  about  5  mm.  higher  up, 
and  finally  through  the  upper  margin  of  the  wound.  Eight  stitches 
were  put  in  on  each  side.  The  action  of  the  lid  was  materially  improved 
and  the  cosmic  result  excellent. 


suture  suffices ;  the  patient  should  be  advised  to  wipe  the 
eye  from  below  upward. 

Entropion,  especially  of  the  lower  lid,  may  also  be 
caused  by  spastic  contractions  of  the  muscular  fibers.  It 
is  seen  most  frequently  in  elderly  people  with  relaxed  eye- 
lids and  small,  deep-set,  or  deficient  eyeballs,  associated 
usually  with  blepharospasm.  The  condition  is  usually 
temporary  and  can  be  corrected  by  simply  drawing  the 
skin  away  from  the  palpebral  fissure  and  securing  it  with 
adhesive  plaster  or  a  Gaillard  suture. 

Cicatricial  entropion  is  a  more  serious  injury  and  gener- 
ally requires  operative  treatment.  It  is  caused  by  cica- 
tricial shortening  of  the  conjunctiva  after  trachoma,  diph- 
theritic conjunctivitis,  burning  or  scalding  of  the  conjunc- 
tiva, and  not  infrequently  after  excessive  therapeutic 
cauterization. 

Symblepharon  is  a  cohesion  between  the  eyelids  and  the 


~ 


DISEASES  OF  THE  EYELIDS  107 

ball  which  sometimes  develops  as  the  result  of  burns  and 
ulceration. 

Sometimes  the  free  edges  of  the  lids  become  adherent 
to  each  other,  in  which  case  the  condition  is  called  ankylo- 
blepharon. 

The  term  blepharophimosis  is  applied  to  a  condition  in 
which  the  palpebral  fissure  is  apparently  shortened  by  the 
passage  of  a  vertical  fold  of  skin  over  the  outer  canthus. 
The  commissure  is  normal  underneath  the  fold  of  skin, 
which  can  be  made  to  disappear  by  outward  traction  with 
the  finger.  If  the  palpebral  margins  have  actually  grown 
together  at  the  outer  commissure,  the  condition  is  more 
correctly  designated  as  anhi/loblephdron. 

3.  Injuries  of  the  Eyelids. 

Injuries  of  the  eyelids  are  very  common.  The  skin 
in  this  region  is  loosely  attached  to  the  underlying  tis- 
sues and  very  extensible,  favoring  the  development  of 
severe  subcutaneous  hemorrhages  which  cause  various  dis- 
colorations,  ranging  from  red  to  dark  blue  or  black.  The 
lids  are  swollen,  particularly  if  there  is  subcutaneous  em- 
physema, as  in  fractures  or  fissures  of  the  orbital  bones, 
which  permit  the  escape  of  air  from  the  nasal  and  other 
cavities  (sinus  frontalis,  etc.).  The  thin,  nasal  wall  of  the 
orbit  is  particularly  liable  to  fracture,  especially  the  crib- 
riform plate  of  the  ethmoid  bone,  and  the  escaping  air  dis- 
tends the  lids  so  that  they  feel  like  an  emphysematous 
lung.  Sometimes  there  is  protrusion  of  the  eyeball. 
These  symptoms,  however,  look  more  alarming  than  they 
really  are  and  the  patient  usually  escapes  with  nothing 
worse  than  a  "black  eye."  A  far  greater  significance 
attaches  to  the  subcutaneous  hemorrhages  caused  by  fract- 
ure of  the  base  of  the  skull  (Plate  10).  In  this  accident 
the  blood  sometimes  is  forced  forward  as  far  as  the  eye- 
lids, and  the  resulting  ecchymosis  in  the  lower  part  of 
the  ocular  conjunctiva  and  in  the  lower  lid  (rarely  also  in 
the  upper)  constitutes  an  important  symptom. 


108  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  10. 

Subcutaneous  Hemorrhage  in  the  Lids  after  Fracture  of  the  Base  of 
the  Skull.— The  hemorrhage  is  more  marked  in  the  upper  than  in  the 
lower  Lid,  which  is  the  opposite  of  what  is  usually  observed.  Patient  is 
24  years  old,  male.  Four  days  before,  he  jumped  from  a  moving  car  and 
struck  mi  the  hack  of  his  head.  He  was  unconscious  twenty-four  hours 
and  complained  of  headache  for  a  long  time  afterward.  No  other  lesion 
was  found.  Cured  after  a  rest  of  several  weeks,  part  of  the  time  in  bed. 
No  permanent  injuries. 

Permanent  injuries  may  result  from  a  cut  severing  the 
upper  lid  or  dividing  one  or  the  other  lid  in  a  vertical 
line,  unless  the  wound  is  promptly  and  carefully  sutured. 
Especial  care  must  be  taken  to  bring  the  edges  of  the 
wound  together  accurately  at  the  free  border  of  the  lids. 
If  the  lower  lid  is  torn  at  the  inner  canthus,  permanent 
interruption  of  the  lower  canaliculus  usually  results  in 
spite  of  the  most  careful  application  of  sutures  ;  this  has 
been  referred  to  on  p.  79.  Fortunately,  the  upper  canali- 
culus under  ordinary  conditions  is  able  to  carry  off  the 
lachrymal  fluid. 

In  powder-burns  the  particles  of  powder  are  best  re- 
moved by  burning  with  the  electric  cautery  after  the 
wound  has  healed. 

4.  Tumors  of  the  Eyelids. 

Benign  Tumors. — Xanthelasma  occurs  in  middle- 
aged  persons,  especially  women,  and  occasionally  requires 
operative  treatment  on  account  of  the  deformity.  The 
patches  are  of  a  yellowish-brown  color  and  slightly  raised 
above  the  surrounding  skin.  Both  eyes  are  usually  af- 
fected, the  patch«'-  being  symmetrically  distributed  above 
and  below  the  inner  canthus. 

Mo// ns<- ma  contagiosum,  as  its  name  implies,  is  apt  to 
spread  over  the  body  of  the  patient  and  infect  those  who 
(•nine  in  contact  with  him.  The  papules  are  as  large  as  a 
pea  oi-  a  cherry,  and  appear  in  large  numbers,  preferably 
on  the  lids  and  their  surroundings.     In  proof  of  the  con- 


Tab.   10. 


Luft.  Anst  F.  Reichhohl,  München. 


DISEASES  OF  THE  CONJUNCTIVA.  109 

tagious  nature  of  the  disease  I  may  state  that  I  inoculated 
myself  with  it  successfully  about  twelve  years  ago,  that 
being  one  of  the  earliest  successful  inoculations  on  record. 
The  growth,  which  was  taken  from  the  eyelid  of  a  child, 
took  six  months  to  develop.  Epidemics  of  the  disease 
have  been  observed  in  schools. 

Milium,  or  an  occluded  sebaceous  gland,  appears  as  a 
small  elevation  which  is  sometimes  confounded  with  mol- 
luscum  contagiosum  in  its  first  stages.  The  shallow  cen- 
tral depression,  however,  through  which  the  milky  contents 
of  the  molluscum  can  be  expressed,  is  not  seen  in  the  mil- 
ium. With  the  microscope  certain  peculiar,  shining, 
spherical  bodies  are  found  in  mollusca  which  establish  the 
diagnosis. 

Each  nodule  must  be  removed  with  the  galvanocautery, 
curet,  etc. 

Fibroma  molluscum,  or  molluscum  simplex,  warts,  and 
cutaneous  corns  are  occasionally  seen ;  also  angiomata, 
telangiectatic  and  cavernous  tumors.  The  latter  are  usually 
congenital,  and  should  be  removed  as  early  as  possible. 

Malignant  Tumors. —  Carcinoma  and  sarcoma,  the 
former  preferably  on  the  palpebral  margin,  the  latter  often 
melanotic,  usually  begin  in  the  tarsus. 


DISEASES  OF  THE  CONJUNCTIVA. 

A.   CONFLUENT  INFLAMMATIONS. 

i.  Simple  Catarrhal  Conjunctivitis. 

^Ye  distinguish  an  acute  and  a  chronic  form.  In  acute 
conjunctivitis  the  inflammatory  symptoms  arc  more  pro- 
nounced and  the  bulbar  conjunctiva  is  involved,  while 
catarrh,  especially  the  chronic  form,  is  usually  limited  to 
the  palpebral  conjunctiva. 

The  objective  symptoms  arc  :  Abnormal  secretion  of 
mucus  or  pus,  congestion,  swelling  of  the  mucous  mem- 
brane producing  a  roughness  in  the  tarsal  conjunctiva, 


110  EXTERNAL    DISEASES  OF  THE  EYE. 

the  formation  of  folds  in  the  region  of  the  fornix,  and 

swelling  of  the  semilunar  fold  and  caruncle.  In  purulent 
catarrh  there  may  be  edema  of  the  bulbar  conjunctiva  and 
the  lids  themselves  are  more  or  less  swollen. 

The  lids  arc  glued  together  in  the  morning  \  the  patient 
complains  of  burning-  and  itching  and  a  gritty  feeling. 
Owing  to  a  film  of  mucus  on  the  cornea  there  is  a  tempo- 
rary haziness,  which  disappears  as  soon  as  the  patient 
wipes  his  eyes.  If  the  layer  of  mucus  is  very  thin,  the 
patient  sees  colored  rings  around  the  lamp  (iridescent 
vision),  as  in  glaucoma.  Photophobia,  blepharospasm, 
and  pain  are  not  marked  as  long  as  the  cornea  is  not  in- 
volved, so  that  the  lids  are  more  easily  separated  than  is 
the  case  in  corneal  inflammations.  Later  in  the  course  of 
chronic  catarrh  the  lid-margins  and  the  cornea  may 
become  inflamed,  especially  in  elderly  people,  giving  rise 
to  the  so-called  marginal  or  catarrhal  ulcer,  or  to  purulent 
ulcers. 

Btiology. — A  variety  of  pathogenic  microorganisms 
are  found  in  the  conjunctival  sae  during  catarrh.  Among 
those  which  are  known  to  produce  conjunctivitis  arc  :  (1) 
the  gonococcus  (sec  gonorrheal  conjunctivitis);  (2)  the- 
pneumococcus  of  Fränkel-Weichselbaum,  which  causes  a 
mild  and  not  necessarily  contagious  form  of  catarrh,  and 
is  found  oftener  in  children  than  in  adults;1  (3)  the  strep- 
tococcus, which  produces  either  simple  or  pseudomem- 
branous diphtheritic  inflammation.  Whether  the  staphy- 
lococci which  are  often  found  in  the  conjunctival  sac  are 
capable  of  causing  conjunctivitis  or  not,  is  still  an  open 
question. 

The  following  bacilli  may  give  rise  to  conjunctivitis: 

(1 )  the  diphtheritic  bacillus  (see  diphtheritic  conjunctivitis)  ; 

(2)  the  Koch-Weeks'  bacillus,  which  under  certain  condi- 
tions sets  up  a  severe,  contagious  inflammation  in  children 

1  [There  arc  a  number  of  observations  on  record,  particularly  those  of 
Harold  Gifford,  which  indicate  that  pneumococcus-conjunctivitis  may 
also  be  an  affection  which  is  distinctly  contagious,  which  attacks  adults, 
which  passes  from  one  eve  1<>  another,  and  which  clinically  is  difficult  to 
differentiate  from  Koch-Weeks  bacillus  conjunctivitis.— Ed.] 


DISEASES  OF  THE  CONJUNCTIVA.  Ill 

and  adults  [acute  contagious  conjunctivitis,  vulgarly  known 
as  "pink  eye." — Ed.]  ;  (3)  the  diplobaciUus  of  Marax  and 
Axenfeld,  the  occasional  cause  of  a  slow,  protracted  form 
of  conjunctivitis.  [It  is  not  infrequently  found  in  stub- 
born cases  of  subacute  conjunctivitis. — Ed.] 

As  far  as  our  present  knowledge  of  simple  catarrhal 
conjunctivitis  goes,  different  bacilli  may  be  found  in 
clinically  identical  forms ;  and,  conversely,  the  same 
bacilli  may  give  rise  to  different  clinical  appearances 
(Bach). 

Among  other  causes  which  produce,  or  at  least  aggra- 
vate, conjunctivitis  may  be  named  :  Bad  ventilation,  dust, 
smoke,  alcoholic  abuse,  blepharitis,  dacryostenosis,  foreign 
bodies  in  the  conjunctival  sac,  etc. 

Diagnosis. — This  is  based  on  the  symptoms  described. 
Corneal  complications  may  be  detected  by  observing  ciliary 
congestion  and  irregularities  in  the  surface  of  the  mem- 
brane. 

Prognosis. — This  is  excellent  in  young  subjects,  al- 
though in  elderly  people  and  in  cases  in  which  the  exciting 
causes  cannot  be  removed,  the  treatment  may  present  some 
difficulties. 

Treatment. — This  is  primarily  concerned  with  the  re- 
moval of  the  exciting  causes.  Locally,  astringents,  either 
applied  by  the  surgeon  himself,  or  in  the  form  of  eye-drops 
or  ointment  entrusted  to  the  patient.  The  mucous  sur- 
faces may  be  painted  with  a  1  per  cent,  to  2  per  cent,  solu- 
tion of  argentic  nitrate  according  to  the  degree  of  purulent 
secretion.  For  a  colly rium  prescribe  zinc  sulphate  0.05- 
0.1  in  10.0  of  distilled  water,  or  1  :  10,000  sublimate  solu- 
tion ;  the  latter  solution  remains  sterile  longer.  If  the  cor- 
nea is  not  involved,  lead  acetate  0.1-0.2  in  10.0  of  distilled 
water,  or  ung.  amvlo-glycerini  (glyceritum  amyli),  may 
be  useful  ;  but  if  the  cornea  is  involved,  incrustations  of 
lead  may  follow  its  use  and  retard  the  healing  of  the  cor- 
neal injury.  In  obstinate  cases  a  variety  of  remedies  must 
be  tried  :  Copper  sulphate,  tannin,  alum  (0.5  per  cent.). 
Collyria  are  to  be  used  once  or  twice  a  day  ;  ointments  are 


112  EXTERNAL   DISEASES  OE  THE  EYE. 

Plate  ii. 

a.  Dermoid  tumor  in  a  child,  aged  1  year.  The  growth  is  congenital 
and  is  growing  very  slowly. 

b.  The  same  in  a  man,  aged  21  years.  The  characteristic  hairs,  often 
seen  in  a  dermoid  tumor,  are  present.  The  tumor  in  this  case  also  has 
grown  very  little  since  birth.  After  removal  a  small,  gray  spot  appeared 
on  the  cornea. 

applied  once  a  day  with  a  glass  rod.  Atropin  is  quite 
unnecessary  unless  there  is  a  corneal  complication.  [Fre- 
quent cleansing  of  the  conjunctival  sacs  with  saturated 
boric-acid  solution,  or  with  boric  acid  and  saline  solution, 
is  advantageous.  If  reaction  is  high,  iced  compresses  are 
useful.  Zinc  is  especially  valuable  in  diplobacillus  con- 
junctivitis.— Ed.] 

2.  Follicular  Conjunctivitis. 

A  chronic  form  of  catarrh,  characterized  by  the  forma- 
tion of  numerous  granulations  on  the  conjunctiva,  more 
particularly  in  the  retrotarsal  folds  (Plate  14,  a).  The 
nodules  appear  singly  or  in  rows,  are  of  a  pinkish-gray 
color,  and  vary  in  size  from  1  to  3  mm. ;  the  larger  ones 
are  more  or  less  transparent. 

The  disease  belongs  to  childhood  and  early  adult  life, 
and  may  run  its  course  without  marked  subjective  symp- 
toms; or  the  child  may  be  troubled  with  blinking  (nicti- 
tatio)  and  inability  to  continue  at  close  work.  As  a  rule, 
there  is  little  or  no  secretion. 

Diagnosis. — Follicular  conjunctivitis  is  often  con- 
founded with  trachoma  ;  but  the  distinction  may  be  made 
by  observing  that  the  granulations  are  most  numerous  in 
the  lower  retrotarsal  fold,  while  in  trachoma  they  are 
found  chiefly  in  the  upper  curve  of  the  fornix. 

Prognosis. — The  disorder  may  run  a  slow  and  tedious 
course;  or  it  may  disappear  without  leaving  a  trace. 

Treatment. — Lead,  either  as  an  ointment  or  in  solution, 
as  a  collyrium  (Plumb,  acet.  0.1-0.2  to  10.0,  aquae  des- 
till.   or   ung.  amylo-glycerini).     [Excellent  colly ria  also 


«5 


Tab.   11 


:/ 


J.Uh.Anst  E Reichhold,  Mändwri. 


DISEASES  OE  THE  CONJUNCTIVA.  113 

are  :  Boric-acid  solution  to  which  a  few  minims  of  alcohol 
to  the  ounce  have  been  added,  and  boric  acid  in  saturated 
solution  ;  applications  of  moderate  astringents  like  tannin 
and  glycerin  (5  per  cent.)  are  suitable ;  but  if  the  disease 
is  stubborn,  the  follicles  should  be  expressed  with  suitable 
forceps. — Ed.] 

3.  Gonorrheal  Conjunctivitis. 

Gonorrheal  conjunctivitis  is  caused  by  infection  of  the 
conjunctival  sac  with  Nasser's  gonococcus ;  and,  while  it 
may  occur  at  all  ages,  is  most  frequently  seen  in  infants, 
in  whom  it  is  due  to  the  entrance  of  genital  secretion  into 
the  eye  at  the  time  of  birth,  or  later  to  contact  with  the 
mother's  soiled  lingers.  Later  in  life  the  genitalia  (now 
and  then  also  in  very  young  girls  who  suffer  from  a  viru- 
lent leukorrhea)  or  another  eye  similarly  affected  are  the 
source  of  infection.  Doctors  and  nurses  are  constantly 
exposed  to  infection  from  this  source. 

The  importance  of  this  disease  cannot  be  overrated  ;  it 
is  the  direct  cause  of  blindness  in  one-third  of  all  the 
cases,  being  surpassed  in  this  respect  only  by  small-pox  in 
countries  where  vaccination  is  not  sufficiently  enforced. 
Most  cases  of  blindness  are  caused  by  ophthalmia  neona- 
torum, which,  in  spite  of  the  higher  standard  of  midwifery 
and  more  competent  medical  treatment  of  the  present  day, 
defies  all  efforts  to  eradicate  it,  because  of  the  negligence 
on  the  part  of  the  persons  in  attendance  in  not  seeking 
medical  assistance  early  enough,  and  because  the  disease  is 
and  always  will  be  dangerous  in  spite  of  the  improved 
methods  of  treatment.  It  is  therefore  much  to  be  desired 
that  the  prophylactic  measures  advocated  by  Crecle  might 
meet  with  more  general  adoption,  especially  in  the  quar- 
ters of  the  poor  and  thoughtless,  who  now  furnish  the 
great  majority  of  virulent  cases. 

Ophthalmia,  or  blennorrhea  neonatorum  [conjunctivitis 
neonatorum],  usually  begins  on  the  third  day  after  birth, 
with  swelling  and  redness  of  the  lids,  and  a  discharge  con- 

8 


114  EXTERNAL    DISEASES  OF  THE  EYE 

Plate  12. 

Gonorrheal  Conjunctivitis  in  the  New-born. 


sisting  of  blood  and  serum,  which  has  been  likened  to 
bouillon.  Both  eves  are  usually  affected,  one  a  little  later 
than  its  fellow.  The  conjunctiva  in  the  first  staue  is  red 
and  swollen,  hut  smooth.  Edema  is  usually  absent  in 
infants. 

After  a  few  days  the  secretions  become  more  purulent, 
the  swelling  of  the  lids  diminishes,  and  the  skin  over  the 
lids  appears  wrinkled  ;  the  conjunctiva  is  soft  and  puck- 
ered into  folds,  the  color  deepens  to  a  dark  red,  the  surface 
is  rough  and  velvety,  and  longitudinal  folds  appear  in  the 
region  of  the  fornix.  At  this  time  thick,  yellow  pus  is 
secreted  in  large  quantities  and  oozes  out  of  the  palpebral 
fissure  (Plate  12)  or  collects  in  the  folds  of  the  conjunc- 
tival cul-de-sac. 

During  this  second,  or  true  gonorrheal  stage,  which 
may  last  for  weeks,  the  cornea  is  in  the  greatest  danger. 
Tin'  secretion,  if  not  removed  from  the  conjunctival  sac, 
attacks  the  cornea  ;  at  first  a  small,  gray  patch  appears  at, 
or  a  little  below,  the  center  of  the  membrane ;  it  increases 
rapidly  in  size  and  is  soon  converted  into  a  suppurating 
nicer,  which  spreads  over  the  entire  surface  and  may  lead 
to  perforation.  If  perforation  takes  place,  the  suppurative 
process  invades  the  deeper  tissues  and  gives  rise  to  viru- 
lent inflammation  in  the  anterior  portion  of  the  eye,  or  even 
to  panophthalmitis.  Sloughing  of  the  entire  cornea  may 
easily  lead  to  prolapse  of  the  lens  ;  in  smaller  perforations 
there  is  more  or  less  adhesion  of  the  iris  to  the  opening, 
and  a  staphyloma  may  result,  li'  the  perforation  is  wry 
small  and  centrally  situated,  the  cornea  may  escape  with  a 
centra/  macula  ;  but  in  this  case  the  lens  may  suffer  from 
the  prolonged  contact  with  the  ulcerated  portion  of  the 
cornea,  the  endothelial  cells  of  the  anterior  capsule  pro- 
liferate, and  an  anterior  capsular  or  pyramidal  cataract 
results  (Plate  34,  a).  The  resulting  corneal  opacity  may 
be   much   less  than  the  lenticular;   but  not  infrequently 


Tab.   12. 


f 


% 


Lütt.  Artst  F.  Reühhold.  München. 


DISEASES  OF  THE  CONJUNCTIVA.  115 

large  white  spots,  or  leukomata,  remain  and  interfere 
materially  with  vision. 

In  older  children  and  in  adults  the  inflammation  runs  a 
more  acute  course.  The  swelling  and  infiltration  of  lids 
and  conjunctiva  are  much  more  marked,  and  there  is 
severe  edema  of  the  bulbar  conjunctiva,  the  edges  of  the 
cornea  being  covered  by  the  overhanging  folds  of  the 
chemotic  membrane.  The  corneal  tissue  is  in  constant 
danger  of  being  eroded  by  the  masses  of  pus  accumulated 
under  these  folds,  and  marginal  ulcers  of  the  cornea  are 
consequently  more  frequent  in  adults  than  in  children. 
Their  detection  is  often  difficult,  because  they  develop 
unseen  under  the  shadow  of  the  swollen  conjunctiva. 
These  marginal  ulcers  are  characterized  by  rapid  spread, 
and  often  result  in  extensive  sloughing  of  the  cornea. 
Under  certain  conditions  an  ulcer  may  develop  in  the 
center. 

In  some  instances  where  the  infiltration  in  the  palpebral 
conjunctiva,  especially  of  the  upper  lid,  is  very  great,  the 
tissues  assume  a  yellowish-grav  color,  resembling  a  diph- 
theritic membrane.  These  eases  are  fraught  with  great 
danger  to  the  cornea. 

Diagnosis. — This  cannot  be  definitely  established 
without  a  microscopic  examination  of  the  secretion  and 
the  detection  in  it  of  gonococci,  although  the  severity  of 
the  process,  in  adults  at  least,  is  such  as  to  leave  no  doubt 
of  the  virulent  nature  of  the  inflammation.  It  must  be 
remembered,  however,  that  both  infants  and  adults  are 
liable  to  occasional  attacks  of  non-virulent  purulent  ca- 
tarrh which  closely  resemble  a  light  attack  of  gonor- 
rhea. Moreover,  it  is  particularly  desirable  that  the 
disease  be  recognized  before  it  has  become  fully  devel- 
oped, in  order  that  the  proper  precautions  may  be  taken 
to  protect  the  unaffected  eye.  For  ordinary  purposes  a 
cover-glass  preparation,  stained  with  fuchsin,  will  give 
all  the  necessary  information  ;  if  diplococci  are  found 
congregated  about  the  nuclei  of  pus-corpuscles,  the  diag- 


116  EXTERNAL   DISEASES  OF  THE  EYE. 

nosis  may  be  considered  established.  For  accurate  demon- 
stration of  the  gonococci  cultures  are  necessary. 

The  prognosis  is  somewhat  more  favorable  in  infants 
than  in  adult  patients.  If  a  new-born  infant  is  seen  early 
enough,  there  is  no  reason  why  the  eye  should  not  be  saved, 
if  the  proper  treatment  is  employed,  with  two  reserva- 
tions :  If  it  is  not  tainted  with  hereditary  syphilis,  or  very 
much  enfeebled  by  other  disease.  In  older  patients  recov- 
ery is  always  very  doubtful ;  total  or  partial  destruction 
of  the  cornea  is  to  be  feared  even  with  the  most  careful 
management.  It  is  one  of  the  most  dangerous  diseases  to 
which  the  eye  is  subject.  I  have  repeatedly  seen  the  loss 
of  both  eyes  take  place  in  spite  of  the  most  energetic  and 
painstaking  treatment. 

Prophylaxis  is  a  matter  of  the  greatest  importance  in 
purulent  ophthalmia.  Crede's  method  is  a  practically  cer- 
tain preventive  of  its  occurrence  in  the  new-born,  and 
may  materially  influence  the  severity  of  the  process  in  the 
adult.  It  consists  in  the  instillation  of  one  drop  of  a  2 
per  cent,  solution  of  silver  nitrate  into  the  eye  immediately 
after  the  first  bath.  No  other  measures  are  necessary 
except  the  proper  precautions  against  subsequent  infection. 
This  method  has  proved  very  successful  and  demonstrates 
conclusively  that  silver  nitrate  is  the  most  effective  remedy 
against  gonococci,  a  very  small  quantity  sufficing  to  check 
their  further  growth. 

All  gonorrheal  patients,  and  those  who  come  in  contact 
with  them  or  with  patients  suffering  from  gonorrheal  con- 
junctivitis, must  be  carefully  warned  of  the  great  danger 
of  infection.  If  one  eye  only  is  affected,  as  frequently 
happens  in  adults,  the  sound  eye  should  be  protected  from 
contact  with  the  infectious  secretion  by  a  collodion  shield 
as  soon  as  the  diagnosis  i-  definitely  settled.  The  eye  is 
covered  with  a  thin  pad  of  cotton  over  which  a  piece  of 
linen  is  fitted,  and  the  v{\^v<  glued  to  the  skin  with  collo- 
dion, after  which  the  entire  dressing  is  given  a  second  coat 
of  collodion.  To  make  sure  thai  infection  has  been  suc- 
cessfully warded  off,  the  shield   must  be  loosened   every 


DISEASES  OF  THE  CONJUNCTIVA.  117 

day,  for  the  first  few  days,  and  the  eye  thoroughly  in- 
spected. [Buller's  shield,  or  a  watch-crystal  fastened  over 
the  sound  eye  with  strips  of  gauze  and  collodion,  is  a 
more  easily  managed  dressing  and  permits  ready  inspection 
of  the  eye. — Ed.]  In  infants  the  application  of  such  a 
shield  is  not  practicable,  nor  is  it  often  necessary,  as  both 
eyes  are  usually  affected  from  the  beginning. 

Treatment. — During  the  entire  course  of  a  gonorrheal 
conjunctivitis  the  first  duty  of  the  attendant  is  to  keep 
the  conjunctival  sac  absolutely  clean  by  constant  removal 
of  the  discharge.  To  reduce  the  swelling  and  inflamma- 
tion ice-cold  compresses  are  applied  at  short  intervals,  the 
eye  being  carefully  wiped  with  a  pledget  of  cotton  every 
time  the  compress  is  changed.  The  compresses  must  be 
washed  in  a  1  per  cent,  solution  of  potassium  perman- 
ganate before  they  are  put  back  on  the  ice,  and  the  same 
solution  should  be  used  by  the  surgeon  in  cleansing  the 
eye  at  each  examination.  In  the  beginning,  while  the  in- 
flammation is  at  its  height,  cold  compresses  should  be 
applied  day  and  night ;  later,  the  cleansing  process  at  least 
must  be  kept  up  during  the  entire  night.  If  the  secretion 
is  very  abundant,  the  attendant  should  separate  the  lids 
every  quarter  of  an  hour,  so  as  to  allow  the  pus  to  run  off; 
but  in  no  case  is  he  to  wipe  the  conjunctival  sac.  That 
duty  must  be  performed  by  the  surgeon  himself,  from  one 
to  three  times  a  day  or  oftener,  as  the  severity  of  the 
process  demands.  [As  collyria  in  purulent  ophthalmia 
the  Editor  prefers  a  saturated  boric-aeid  solution,  or  mer- 
curic chlorid,  1  :  8000,  or  formaldehyd,  1  :  6000.  He  has 
also  had  excellent  results  with  potassium-permanganate 
solution  (1  :  2000)  used  in  copious  irrigations — J  liter  at  a 
time.  Vaselin  rubbed  on  the  lids  and  introduced  into 
the  conjunctival  sac  is  of  great  advantage.  Recently, 
protargol  and  argonin  have  been  advocated  in  place  of 
silver  nitrate  in  purulent  ophthalmia.  They  may  be  used 
in  from  2  to  5  per  cent,  solutions. 

Silver  nitrate  is  the  best  remedy  for  checking  the  secre- 
tion.    As  a  strong  caustic  solution  would  endanger  the 


118  EXTERNAL   DISEASES  OF  THE  EYE. 

Plate  13. 

a.  Diphtheritic  conjunctivitis  in  ;i  small  boy.  This  picture  shows  a 
higher  degree  of  inflammatory  swelling  and  injection  of  the  conjunctiva 
than  the  last.  The  skin  of  the  lower  lid  and  the  region  about  the  inner 
can  thus  are  infiltrated  and  eroded  in  places  by  the  purulent  discharge. 

h.  The  everted  upper  lid  of  the  same  patient,  showing  the  deep  diph- 
theritic infiltration  of  the  conjunctiva,  which  is  of  a  yellowish-gray  color. 


vitality  of  the  cornea,  a  2  per  cent,  solution  is  usually 
employed;  but  in  neglected  cases,  in  which  the  swelling 
of  the  conjunctiva  is  unusually  great,  it  may  be  necessary 
to  use  the  solid  stick.  The  more  active  the  purulent 
secretion  the  more  frequent  should  be  the  applications  ; 
in  adults  two  brushings  a  day  may  be  needed;  in  fact,  the 
nitrate  should  be  applied  as  soon  as  the  eschar  has  sepa- 
rated, and  that,  in  turn,  depends  on  the  amount  of  dis- 
charge. The  important  point  to  be  remembered  in  cau- 
terizing the  conjunctiva  is  that  it  must  not  be  practised 
until  there  is  a  free  discharge  of  pus ;  in  other  words,  not 
before  the  second  or  gonorrheal  stage.  As  long  as  the 
conjunctiva  is  tense  and  swollen  and  there  are  fibrinous 
deposits  and  discolored  areas  cauterization  is  harmful. 

When  the  silver  nitrate  is  to  be  applied,  the  child  is 
made  to  assume  the  position  described  on  p.  24.  Each 
lid,  in  infants  and  adults,  is  to  be  everted  separately  and 
thoroughly  painted  with  the  solution,  but  in  such  a  way  as 
to  avoid  contact  with  the  cornea.  The  retrotarsal  folds, 
which  are  always  the  seat  of  greatest  -welling,  should  re- 
ceive special  attention.  After  the  desired  eschar  is  formed, 
the  excess  of  nitrate  is  to  be  washed  away  with  water,  or, 
if  the  mitigated  stick  has  been  used,  with  a  saline  solution, 
to  prevent  injury  to  the  cornea.  Protargol  has  lately  been 
recommended  fortius  purpose,  but  its  efficacy  still  remains 
to  be  proved. 

Ulceration  of  the  cornea  is  not  a  contraindication  for 
silver  nitrate  ;  on  the  contrary,  it  is  then  the  only  avail- 
able remedy  and  must  be  applied  with  all  the  more  thor- 
oughness.    The  conjunctival  sac  should  be  carefully  freed 


Tab.   13. 


Lith,Anst  F.  Rewhhold.  München,. 


DISEASES  OF  TUE  CONJUNCTIVA.  119 

from  adherent  particles  of  secretion  before  silver  nitrate  is 
applied. 

In  adults  it  is  advisable  in  severe  cases  to  divide  the 
outer  canthus  by  a  horizontal  incision  with  scissors.  It 
facilitates  eversion  of  the  lid,  allows  the  conjunctival  sac 
to  be  cleansed  more  readily,  and  relieves  the  pressure  on 
the  bulb  which  is  so  dangerous  to  the  cornea. 

4.  Diphtheritic  Conjunctivitis. 

This  disease,  which  is  caused  by  the  Löffler  bacillus, 
produces  alterations  of  varying  degrees  and  clinical  ap- 
pearances. In  one  case  the  diphtheritic  symptoms  are 
most  conspicuous — intense  inflammation,  swelling  of  the 
lids,  deep  infiltration  of  the  conjunctiva  (Plate  13,  b),  pro- 
ducing a  grayish-yellow  discoloration  and  followed  Im- 
partial necrosis.  Another  case  may  simulate  the  crovjious 
form  of  inflammation  :  the  exudation  is  superficial  and 
leads  to  the  formation  of  a  grayish-white  or  yellowish, 
fibrinous  membrane  containing  few  cellular  elements, 
which  is  detached  with  more  or  less  difficulty  and  reap- 
pears again  and  again  for  several  days,  without  inflicting 
any  more  serious  injury  on  the  mucous  membrane  than  a 
slight  bleeding.  The  false  membrane  usually  does  not 
extend  over  the  bulbar  conjunctiva.  The  clinical  picture 
in  both  the  croupous  and  the  diphtheritic  forms  varies 
widely  according  to'  the  extent  and  intensity  of  the 
process. 

In  severe  diphtheritic  conjunctivitis  the  infiltration  in- 
volves the  bulbar  conjunctiva  and  may  threaten  the  cornea  ; 
the  danger  to  vision  in  such  cases  is  very  great,  total 
blindness  often  resulting  from  sloughing  of  the  cornea. 
Sometimes  the  skin  of  the  adjacent  area  shows  diphtheritic 
symptoms  (Plate  13),  the  neighboring  lymph-glands  are 
swollen,  and  there  is  general  prostration  with  fever.  The 
necrosis  may  be  so  extensive  that  the  conjunctiva  looks 
like  a  piece  of  yellow  rubber.  Tn  the  course  of  ten  to 
fourteen   days    the   diphtheritic    inflammation    undergoes 


120  EXTERNAL  DISEASES  OE  THE  EYE. 

resolution,  the  secretions  of  blood  and  serum  give  place  to 
a  mure  and  more  purulent  discharge,  the  ulcers  in  the  con- 
junctiva heal,  and  the  resulting  eicatriaial  contraction  may 
produce  entropion.  The  greater  the  intensity  of  the  diph- 
theritic or  croupous  inflammation  the  more  abundant  the 
discharge  of  pus  in  the  second  stage,  so  that  the  latter  is 
sometimes  spoken  of  as  the  gonorrheal  stage. 

Diagnosis. — Now  that  the  diphtheria-bacillus  is 
known,  the  diagnosis  presents  less  difficulties  than  for- 
merly. The  diphtheritic  nature  of  croupous  conjuncti- 
vitis, first  demonstrated  by  bacteriologic  methods,  is  clin- 
ically confirmed  by  the  observation  that  simple  laryngeal 
diphtheria  may  be  contracted  from  a  patient  suffering 
from  diphtheritic  conjunctivitis.  In  addition,  bacteriol- 
ogy teaches  us  that  other  pathogenic  microorganisms,  such 
as  staplij/locoeci,  pneumococci,  and  especially  streptococci, 
are  capable  of  producing  both  the  superficial,  pseudo- 
membranous, and  the  deep,  necrotic  form  of  conjunctivitis. 
Staphylococci  and  streptococci  are  nearly  always  found 
associated  with  the  diphtheritic  bacillus.  The  Ernst- 
Neisser  method  of  staining  affords  the  readiest  means 
of  testing  the  virulence  of  the  bacilli  found.  The  fact 
that  fibrinous  deposits  and  suspicious  areas  are  sometimes 
seen  in  gonorrheal  conjunctivitis  renders  a  bacteriologic 
examination  imperative. 

The  prognosis  depends  on  the  severity  of  the  inflam- 
matory process.  It  is  materially  better  since  the  introduc- 
tion of  diphtheria-antitoxin,  except  when  streptococci 
form  the  principal  exciting  cause,  as  these  microorganisms 
appear  to  be  specially  dangerous  to  the  cornea.  If  exten- 
sive sloughing  of  the  cornea  has  set  in,  even  antitoxin  is 
unable  to  stay  the  process. 

Treatment. — Subcutaneous  injections  of  Bchring's 
diphtheria-antitoxin  should  be  practised  as  early  as  pos- 
sible. In  light  cases  scrupulous  cleanliness  is  usually  all 
that  is  needed.  In  the  gonorrheal  stage  painting  with  a 
!_•_>  per  cent,  solution  of  silver  nitrate  is  indicated,  (/old 
compresses   may   be   used  with    some    advantage   in   the 


DISEASES  OF  THE  CONJUNCTIVA.  121 

initial  stages ;  in  the  infiltrative  form  hot  applications  are 
more  suitable.  As  the  disease  is  extremely  infectious  the 
patient  must  be  kept  in  strict  isolation. 

5.  Trachoma  (Granular  Conjunctivitis). 

This  disease,  which  is  also  known  as  Egyptian  or  gran- 
ular ophthalmia,  arises  by  infection,  the  acute  form,  charac- 
terized by  the  presence  of  a  more  or  less  purulent  secre- 
tion, being  particularly  contagious.  For  this  reason  both 
eyes  are  usually  affected.  The  disease  often  lasts  for 
years ;  in  the  chronic  form,  which  is  the  most  common  by 
far,  there  is  little  or  no  secretion. 

Trachoma  is  often  so  insidious  in  its  onset  that  it  es- 
capes detection  for  a  long  time.  When  it  is  well  estab- 
lished the  palpebral  conjunctiva  and  retrotarsal  folds 
become  uniformly  swollen  and  present  a  rough,  uneven 
appearance. 

Two  varieties  of  granulations  are  distinguished  : 

1.  The  so-called  papillary  granulations;  the  papillae 
which  are  normally  discernible  in  the  tarsal  conjunctiva 
and  produce  the  peculiar  velvety  appearance  seen  in  all 
forms  of  chronic  catarrh,  become  enormously  hypertrophied 
and  form  raspberry-like  elevations.  They  are,  as  a  rule, 
more  numerous  in  the  upper  than  in  the  lower  tarsal  con- 
junctiva. 

2.  Follicular  granulations,  most  abundant  in  the  retro- 
tarsal folds,  forcing  their  way  through  the  superficial 
layers  of  the  mucous  membrane  in  the  form  of  hemispher- 
ical, semitransparent  bodies  of  a  grayish-pink  color, 
arranged  in  dense  parallel  rows  and  converting  the  retro- 
tarsal folds  into  a  thick,  unyielding  mass.  The  granula- 
tions are  less  conspicuous  in  the  tarsal  conjunctiva?,  because 
they  are  smaller  and  less  numerous  and  completely  buried 
in  the  swollen,  papillary  mucous  membrane  ;  but  even  in 
this  situation  they  may  sometimes  be  seen  as  small,  bright, 
circular  spots  of  a  yellowish  color. 

A  characteristic  feature  of  the  disorder  is  the  appear- 


12'2  EXTERNAL    DISEASES  OF  THE  EYE. 

Plate  14. 

a.  Trachoma  of  the  Lower  Lid.— Male,  aged  24  years.  A  few  granu- 
lations an-  seen  in  the  retrotarsal  fold  of  the  upper  lid.     His  occupation 

(carpentry)  obliges  him  to  work  in  a  dusty  atmosphere,  and  no  doubt  is 
partly  responsible  for  the  disease.  We  observe  the  conjunctival  injection 
characteristic  of  conjunctival  catarrh. 

b.  Subconjunctival  Ecchymoses  (Hyphsema  Conjunctivae).— The 
hemorrhage  in  this  case  was  caused  by  a  slight  injury,  but  the  same 
symptom  sometimes  occurs  in  whooping-cough. 


ance,  in  most  cases,  of  the  corneal  complication  known  as 
pannus  (see  Plate  28,  a).  This  consists  of  a  grayish-pink, 
granular  deposit  of  vascular  tissue,  which  usually  begins 
at  the  upper  margin  of  the  cornea  and  gradually  extends 
downward  to  end  in  a  fairly  well-defined  horizontal 
boundary.  The  blood-vessels  forming  the  pannus  com- 
municate with  the  conjunctival  vessels  and  form  a  venous 
plexus  in  the  cellular  tissue  of  the  deposit,  which  during 
the  greater  part  of  the  process  is  limited  to  the  space  be- 
tween the  corneal  epithelium  and  Bowman's  membrane, 
but  may  in  the  later  stages  penetrate  more  deeply.  Pannus 
is  in  every  respect  analogous  to  trachomatous  disease  of 
the  conjunctiva,  and  is  therefore  more  than  a  simple  me- 
chanical irritation  due  to  friction  of  the  granulations.  It 
may  cause  more  or  less  visual  disturbance,  or  even  total 
blindness. 

Cicatrization  is  a  conspicuous  feature  of  the  last  stages 
of  trachoma.  As  the  retrotarsal  folds  regain  their  normal 
thickness,  the  mucous  membrane  covering  them  contracts 
as  it  is  gradually  converted  into  connective  tissue,  and  a 
network  of  grayish-white  scar-lines  makes  its  appearance 
on  the  tarsal  conjunctiva.  These  cicatricial  changes  and 
the  atrophy  which  occurs  in  the  tarsal  plates  give  rise  to 
entropion,  and  the  friction  of  the  cilia  on  the  cornea  in 
turn  aggravates  the  pannus,  so  that  ulceration  of  the  cornea 
not  infrequently  results. 

Trachoma  is  a  veritable  curse  to  the  countries  where 
the  disease   is  endemic  ;   its   victims  suffer  for  years  and 


Tab.    14. 


Li/h.  Anst  F.  Rei.ciih.old.  München 


DISEASES  OF  THE  CONJUNCTIVA.  123 

are  usually  incapacitated  for  work  most  of  the  time ;  many 
of  them  become  Mind. 

Fortunately,  its  geographical  distribution  is  limited.  It 
occurs  most  frequently  in  Arabia  and  in  Egypt  ;  ii.  Europe 
the  inhabitants  of  low-lying  regions  (Belgium,  Holland, 
Hungary,  the  countries  bordering  on  the  lower  Danube, 
and  Italy)  suffer  most,  the  higher  regions  being  exempt 
from  the  disease.     The  poorer  classes  are  usually  attacked. 

The  subjective  symptoms  are  essentially  the  same  as 
those  of  catarrh.  Ptosis  is  a  more  or  less  constant  symp- 
tom in  the  early  stages  and  gives  the  patient  a  character- 
istic appearance.  As  the  cornea  becomes  involved  the 
discomfort  of  the  patient  increases,  and  if  the  pan n us  in- 
vades the  pupil,  vision  is  affected. 

The  course  varies  widely,  according  to  the  severity  of 
the  process  and  its  tendency  to  acute  exacerbations  or 
chronicity  ;  the  most  unpleasant  feature  is  the  constant 
occurrence  of  relapses,  even  after  recovery  seems  to  be 
established,  although  they  are  partly  due  to  the  patient's 
neglect  in  abandoning  the  treatment  too  soon.  In  some 
cases  papillary  granulations  are  more  conspicuous  ;  in 
others  the  follicular  type  preponderates ;  in  a  third  class 
of  cases  the  two  forms  are  found  associated.  During  the 
last  stages  cicatricial  trachoma  and  its  disastrous  sequela? 
are  often  observed.  The  latter  include  entropion,  trichi- 
asis, xerosis  of  the  conjunctiva,  connective-tissue  change 
of  the  cornea,  and,  finally,  a  general  devastation  of  the 
conjunctival  cnl-de-sac  by  Symblepharon.  On  the  other 
hand,  the  pannus  may  disappear  under  appropriate  treat- 
ment, and  regeneration  of  the  conjunctiva  take  place  if 
cicatrization  has  not  been  too  extensive. 

The  cause  of  trachoma  is  a  specific  poison,  the  exact 
nature  of  which  we  do  not  know  as  yet,  although  specific 
microorganisms  of  trachoma  have  been  described  by  more 
than  one  observer.  Certain  external  conditions,  such  as 
crowded  quarters,  poverty,  bad  air,  and  a  low  altitude, 
undoubtedly  tend  to  foster  the  disorder.  An  interesting 
fact  in  connection  with  the  relation  of  trachoma  to  alti- 


124  EXTERNAL  DISEASES  OF  THE  EYE. 

tude  is  that  the  inhabitants  of  Switzerland  have  so  far 
escaped  infection,  although  numbers  of  Italian  laborers 
suffering  from  the  disease  come  into  the  country  every 
year  and  live  in  tolerable  proximity  to  the  natives.  It 
has  also  been  observed  that  recovery  from  the  disease  is 
hastened  by  sojourn  in  the  mountainous  regions  of  Switz- 
erland and  the  Caucasus.  [According  to  Burnett,  trach- 
oma may  occur  at  an  altitude  of  4700  feet.  Van  Millen- 
gen  denies  the  influence  of  altitude  and  the  immunity  of 
certain  races.  Nevertheless  the  disease  is  almost  unknown 
in  pure  negroes. — Ed.] 

The  diagnosis  in  the  initial  stage  is  often  very  dif- 
ficult; indeed,  it  may  be  impossible  at  first  to  distinguish 
the  disease  from  follicular  conjunctivitis.  Generally 
speaking,  the  granulations  in  trachoma  are  most  numer- 
ous in  the  upper  retrotarsal  fold,  which,  like  its  fellow 
behind  the  lower  lid,  soon  becomes  thickened  and  as- 
sumes a  reddish-yellow  tint.  Sometimes  trachoma  is 
confounded  with  spring-conjunctivitis,  although  it  has 
nothing  whatever  in  common  with  that  disorder.  In 
spring-conjunctivitis  the  nodules  are  more  flattened  than 
in  trachoma,  and  slightly  pedunculated,  while  the  rest  of 
the  tarsal  conjunctiva  is  covered  with  a  peculiar  milky 
film.  If,  in  addition,  the  characteristic  proliferations 
about  the  corneal  margin  are  present,  the  distinction  is 
easily  made;  moreover,  there  are  no  granulations  in 
spring-conjunctivitis.  Acute  trachoma  may  be  mistaken 
for  gonorrheal  conjunctivitis. 

Prognosis. — It  follows  from  what  has  been  said  that 
the  prognosis  is  exceedingly  grave;  at  least  in  respect  to 
a  speedy  recovery,  especially  if  the  patient  is  not  in  good 
circumstances  and  unable  to  follow  the  protracted  course 
of  treatment   necessary  to  effect  a  cure. 

Treatment. — As  the  disease  is  a  long  and  tedious  one. 
the  treatment  must  be  proportionately  assiduous.  It  may 
be  divided  into  three  methods  :  Local  medication,  me- 
chanical treatment,  and  operative  procedures.     Recovery 


DISEASES  OF  THE  CONJUNCTIVA.  125 

is  materially  assisted  by  favorable  external  conditions, 
especially  pure  air,  if  possible  in  a  mountainous  region. 

Among  local  remedies  silver  nitrate  in  2  per  cent,  solu- 
tion, and  copper  sulphate,  in  the  form  of  a  stick,  or  a 
crystal  (the  end  of  which  has  been  rounded  off  by  rub- 
bing it  on  a  wet  cloth),  or  in  the  form  of  an  ointment,  are 
recommended.  Both  remedies  are  usually  applied  once  a 
day  ;  in  severe  inflammation  with  active  secretion  silver 
nitrate  is  imperatively  demanded.  (The  greater  the  secre- 
tion the  more  energetically  the  nitrate  should  be  applied.) 
After  the  discharge  has  ceased,  treatment  with  copper- 
sulphate  crystal  is  to  be  begun  and  continued  for  months 
or  even  years.  The  conjunctiva  is  carefully  gone  over 
with  the  crystal  as  often  as  once  a  day  at  first,  later 
at  longer  intervals,  until  the  swelling  has  entirely  sub- 
sided and  the  mucous  membrane  appears  white  and  smooth. 
Later  on  the  patient  may  be  directed  to  paint  his  eyes 
himself  with  an  amylo-glycerin  salve  containing  ^-1  per 
cent,  copper  sulphate.  Some  patients  even  learn  to  use 
the  crystal.  [Excellent  applications  which  may  be  used 
at  home  are  tannin  and  glycerin  (5  per  cent.),  or  boro- 
glycerid  (20  per  cent.). — Ed.]  If  a  relapse  occurs,  with 
renewed  secretion,  the  silver-nitrate  solution  is  again 
resorted  to,  unless  the  irritation  is  too  great,  in  which 
case  a  weak  sublimate  solution  may  be  substituted.  A 
few  drops  are  instilled  into  the  conjunctival  sac  and  wet 
compresses  applied  to  allay  the  inflammation. 

The  granulations  are  best  removed  by  mechanical 
means  :  By  picking  them  out  one  by  one  with  a  needle 
and  expressing  their  contents  between  the  thumb-nails,  or 
by  squeezing  them  out  with  Knapp's  roller-forceps.  They 
may  also  be  destroyed  with  the  galvanocautery.  Kein- 
ing's  method  of  brushing  the  granulations  daily  with  a 
1  :  2000  sublimate  solution  combines  mechanical  removal 
with  medicinal  action.  Excision  of  the  diseased  retro- 
tarsal  folds  is  apt  to  be  followed  by  grave  cicatricial 
changes  in  the  conjunctiva  and  is  not  to  be  recommended. 


126  EXTERNAL    DISEASES  OF  THE  EYE. 

On  the  other  hand,  the  deformities  of  the  lids  which  often 
result  must  be  corrected  by  surgical  means. 

Pannus  usually  requires  no  special  treatment.  If  the 
vascular  tissue  is  unusual ly  thick,  cauterization  may  be 
practised  with  great  care.  If  ulcers  develop  in  the  cornea, 
copper  sulphate  must  be  used  instead  of  silver  nitrate  [and 
the  treatment  suitable  for  corneal  ulcer  instituted. — Ed.]. 
The  patient  and  his  attendants  should  be  duly  impressed 
with  the  importance  of  observing  proper  precautions 
against  the  spread  of  the  disease.  If  possible  the  patient 
should  be  isolated,  especially  if  the  disease  appears  in 
large  bodies  of  men,  as  in  an  army. 

6.  Spring=conjunctivitis  (Fruehjahr's  Catarrh). 

Spring-catarrh  is  the  only  process  in  the  human  body, 
with  the  exception  of  freckles,  that  is  exclusively  depend- 
ent on  atmospheric  heat,  so  much  so  that  it  does  not  attain 
its  full  development  in  cool  seasons.  It  is  a  diffuse  in- 
flammation, involving  the  entire  conjunctiva,  although 
localized  deposits  are  sometimes  observed. 

The  disease  is  quite  rare  in  some  localities,  and  occurs 
most  frequently  in  young  men,  giving  them  a  strikingly 
pale  and  languid  appearance  and  often  lasting  for  years. 
Owing  to  the  slight  degree  of  ptosis  which  is  usually 
present  the  patients  have  the  same  dull,  sleepy  look  that 
is  seen  in  trachoma. 

One  characteristic  symptom  is  a  peculiar  yellowish-red 
discoloration  of  the  conjunctiva  on  either  side  of  the  cornea 
(Plate  15,  d).  The  remaining  objective  phenomena  may 
be  divided  into  three  groups  : 

1.  Hypertrophy  at  the  sclerocorneal  junction,  consisting 
of  smooth,  semitransparent  nodules,  of  pinkish  color  and 
waxy  appearance,  found  chiefly  on  either  side  of  the 
cornea,  but  occasionally  encroaching  on  the  upper  and 
lower  segments  of  the  limbus  (Plate  15,  a  and  d).  These 
nodules  never  undergo  degeneration. 

2.  The  -o-called  tessellated  or  pavemewt-gi'anuktiions  on 
the  tarsal  conjunctiva  (so  called  on  account  of  their  rescm- 


DISEASES  OF  THE  CONJUNCTIVA.  127 

bianco  to  street-pavement).  They  consist  of  hard,  flat- 
tened masses,  pinkish  in  color,  and  upon  close  inspection 
are  seen  to  be  slightly  pedunculated  (Plate  15,  b).  The 
surface  of  these  granulations  often  exhibits  a  bluish  tint, 
which  may  extend  over  the  rest  of  the  tarsal  conjunctiva, 
constituting  the  third  symptom,  viz.: 

3.  Milky  opacity,  in  some  places  like  a  delicate  cau- 
terization-film, in  others  resembling  a  plate  of  smooth, 
bluish-white  enamel  (Plate  15,  c). 

These  symptoms  are  not  always  found  associated  in 
every  case.  Any  one  of  the  three  groups  may  be  wanting, 
or  they  may  be  present  in  varying  degrees  of  intensity. 
The  hypertrophied  limbus  may  encroach  upon  and  practi- 
cally conceal  the  cornea  on  all  sides ;  or  this  symptom  may 
be  absent  altogether  and  the  granulations  on  the  tarsal 
conjunctiva  may  attain  such  proportions  as  to  cause  ulcer- 
ations in  the  cornea  by  their  friction  (rarely).  In  other 
eases  they  may  be  very  few  in  number,  scattered  here  and 
there  in  small  groups,  while  the  intervening  tissue  exhibits 
the  milky  opacity  which  has  been  described. 

The  limbus-form  is  often  followed  by  the  formation  of 
a  small  crescentic  opacity  in  the  cornea,  running  parallel 
to  the  periphery  and  resembling  a  segment  of  arcus 
senilis  ;  it  often  persists  for  years  after  the  disease  has  run 
its  course. 

A  more  or  less  constant  symptom  is  found  in  the 
mucous  or  mucopurulent  secretions  which  collect  in 
threads  on  the  retrotarsal  folds  and  surrounding  tissues. 
This  gives  rise  to  some  of  the  symptoms  seen  in  catarrh, 
as  itching,  stinging  and  burning  pains,  inability  to  do  fine 
work,  and  gluing  of  the  lids  in  the  morning.  General 
aggravation  of  the  symptoms  usually  follows  exposure  to 
excessive  heat.  The  disorder  appears  to  be  inflnenced 
more  by  heat  than  by  the  direct  action  of  the  sun,  the 
patients  suffering  less  severely  in  high  altitudes  in  spite  of 
the  greater  power  of  the  sun's  rays. 

The  diagnosis  is  based  on  the  state  of  the  weather  and 
the  pathologic  changes  described.     The  disease  is  some- 


128  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  15. 

Spring-conjunctivitis. — a.  Patient  is  a  robust  and  otherwise  healthy 
farmer,  24  years  old.  In  winter  and  during  a  protracted  spell  of  cool 
weather  in  summer  the  disease  practically  disappears;  moderate  amount 
of  secretion.  The  conjunctiva  of  the  lower  lid  is  covered  with  a  milky 
film  ;  that  of  the  upper  is  normal.  The  tissues  about  the  corneal  margin 
arc  hypertrophied  and  encroach  to  the  extent  of  from  1  to  2  mm.  on  the 
membrane. 

b  and  c.  Clerk,  aged  19  years.  For  the  last  three  years  the  inflamma- 
tion has  regularly  made  its  appearance  in  May,  and  lasted  the  entire  sum- 
mer. There  are  no  follicular  granulations  to  be  seen  anywhere.  The 
right  upper  lid  shows  the  tessellated  appearance  of  the  hypertrophied 
tissues;  on  the  left  lower  lid  the  milky  opacity  is  illustrated. 

d.  In  this  patient  (male,  aged  14  years)  the  characteristic  yellowish  in- 
jection is  clearly  seen  to  the  temporal  side  of  the  cornea,  merging  into 
the  marginal  hypertrophy,  which  is  also  well  marked. 


times  mistaken  for  trachoma  (q.  v.)  and  marginal  eczema 
of  the  cornea  (marginal  keratitis).  The  latter  can  always 
be  recognized  by  the  ensuing  ulceration  in  the  cornea. 
When  the  disease  occurs  in  elderly  people,  as  it  occasion- 
ally does,  some  difficulty  may  be  experienced  in  distin- 
guishing it  from  an  incipient  cancer.  Even  a  microscopic 
examination  of  the  hyperplastic  tissue  about  the  limbus 
does  not  always  clear  up  the  diagnosis,  since  the  same 
abnormal  preponderance  of  epithelial  elements  and  ten- 
dency to  send  out  long  villous  processes  into  the  subjacent 
connective  tissue  (which  also  shows  marked  hypertrophy) 
are  seen  in  spring-conjunctivitis.  Neither  granulations 
nor  follicle-formation  can  be  detected  with  the  microscope. 

Prognosis. — Two  factors  combine  to  render  the  prog- 
nosis unfavorable:  Our  inability  to  control  the  chief  ex- 
citing cause,  the  weather,  and  the  want  of  a  specific 
remedy. 

Treatment. — Although  all  kinds  of  remedies,  new  and 
old,  have  been  suggested,  the  treatment  is  still  essentially 
palliative.  A  1  percent,  lead  ointment  may  be  used,  pro- 
viding there  is  no  corneal  ulceration.  Good  results  have 
been  obtained  in  some  cases  by  inunctions  and  massage 
with    1-2    per  cent,   yellow   mercuric-oxid    ointment,   or 


Tab.   1 


I 


Jr 


% 


Lüh.Atist  tl ReictüwUi 


DISEASES  OF  THE  CONJUNCTIVA.  129 

with  dilute  acetic  acid,  1  drop  to  10-20  drops  of  water, 
as  a  collyrium.  Relief  is  sometimes  obtained  from  sur- 
gical removal  of  the  larger  nodules.  [Boroglycerid  act- 
well  ;  the  internal  administration  of  arsenic  has  some 
repute. — Ed.] 


B.  CIRCUMSCRIBED  INFLAMMATIONS  OF  THE 
CONJUNCTIVA. 

In  contradistinction  to  the  confluent  forms  of  inflamma- 
tion, in  which  the  palpebral  conjunctivae  are  chiefly  in- 
volved, we  find  that  in  the  circumscribed  varieties  the 
pupillary  region  is  the  principal  seat  of  the  lesion.  The 
most  important  representative  of  the  group  is 

7.  Eczematous,  Phlyctenular,  or  Scrofulous  Conjunctivitis. 

This  is  absolutely  the  commonest  form  of  all  inflamma- 
tions of  the  conjunctiva,  general  or  circumscribed.  Horner 
gave  it  the  name  of  eczema.  Its  dermoid  character  be- 
comes manifest  by  the  distinct  clinical  association  witli 
eczema  of  the  lids,  face,  and  head,  on  the  one  hand,  and 
of  the  cornea  itself,  on  the  other,  and  by  its  appea ranee, 
in  common  with  all  other  forms  of  eczema,  in  scrofulous 
subjects.  In  the  absence  of  a  scrofulous  habit,  some 
reduced  condition  of  health  and  nutrition,  either  from 
anemia  or  as  a  result  of  measles,  scarlatina,  pertussis,  etc., 
will  usually  be  recognized  as  the  predisposing  cause.  The 
disease  occurs  most  frequently  during  the  scrofulous 
period — i.  e.,  in  childhood  ;  rarely  in  the  first  year  of  life 
or  after  puberty.  It  rarely  appears  for  the  first  time  in 
adult  life,  but  is  sometimes  seen  in  persons  who  have  had 
an  attack  in  their  childhood. 

Like  other  diseases  of  the  eye,  phlyctenular  conjunc- 
tivitis chiefly  attacks  the  ill-fed  and  ill-kept  children  of 
the  poor.  We  find  associated  with  it  swollen  submaxil- 
lary and  cervical  glands,  chronic  nasal  catarrh  and  eczema 
of  the  nasal  mucous  membrane,  and  eczema  of  the  upper 
lip.     [The  rhinopharyngeal  lesions  are  always  present  in 


130  EXTERNAL  DISEASES  OF  THE  EYE. 

these  cases,  and  if  they  are  not  actually  the  cause  of  many 
attacks,  certainly  aggravate  them  ;  in  short,  they  must  be 
cured  if  the  disease  is  to  be  eradicated. — Ed.]  The  lip 
and  the  nose  eventually  become  the  seat  of  an  unsightly 
swelling,  which  combines  with  the  general  puffiness  of  the 
face  to  form  a  characteristic  clinical  picture  in  cases  of 
long  standing.  If  the  cornea  is  involved  in  the  infiltra- 
tive process,  the  excessive  lachrymation,  by  its  constant  ir- 
rigation of  the  lids,  produces  marginal  eczema  and,  later, 
spasm  and  photophobia,  on  account  of  which  the  children 
hold  their  dirty  hands  over  their  eyes  or  bury  their  faces 
in  the  pillow  and  thereby  aggravate  the  condition. 

Although  eczema  of  the  conjunctiva  and  corneal  eczema 
occur  together  or  within  a  short  interval  of  each  other, 
and  are  therefore  parts  of  the  same  process,  we  shall  dis- 
cuss the  two  conditions  separately,  because  prognosis  and 
treatment  are  materially  different  in  the  two  affections. 

Unless  the  pustules  are  very  numerous,  eczema  of  the 
conjunctiva  does  not  produce  any  marked  irritation,  as  the 
general  appearance  of  the  patient  shows.  Lachrymation 
may  be  somewhat  excessive,  and  some  photophobia  may 
be  present ;  but,  as  a  rule,  the  eye  can  be  opened  without 
much  difficulty.  If  the  patient  complains  of  irritation, 
the  cornea  must  be  carefully  examined  for  eczema. 

The  seat  of  predilection  is  the  circumcorneal  zone, 
especially  the  limbus  or  sclerocorneal  junction.  This  so- 
called  "  marginal  eczema"  [marginal  phlyctenular  kera- 
titis] is  the  commonest  manifestation  of  the  process  in  the 
cornea  und  in  the  conjunctiva.  The  more  remote  portions 
of  the  conjunctiva  are  less  subject  to  the  disease.  The 
retrotarsal  folds  and  tarsal  conjunctiva?  are  exempt  or,  at 
most,  exhibit  catarrhal  symptoms. 

The  size  of  the  pustules  is  inversely  proportional  t<> 
their  number;  usually  they  measure  from  1  to  2  mm.; 
but  if  they  are  very  few  in  number  they  may  attain  twice 
that  size  (3  to  4  mm.).  Sometimes  the  pustules  are  so 
minute  that  they  can  be  recognized  as  elevations  only  by 
the  disturbance   of   reflection   which   they   produce;   the 


DISEASES  OF  THE  CONJUNCTIVA.  131 

conjunctiva  and  the  cornea  look  as  if  they  were  sprinkled 
with  glass-dust.  As  each  individual  pustule,  whether 
large  or  small,  is  surrounded  by  a  zone  of  inflammatory 
tissue,  the  appearance  in  this  form — when  the  pustules  are 
very  minute — resembles  the  red  injection  and  swelling  of 
catarrh,  so  that  the  term  eczemaious  catarrh  is  used  with 
great  propriety.  From  the  fact  that  the  lids  become 
much  swollen  and  inflamed,  these  cases  are  also  designated 
as  catarrh  with  swelling.  Eczematous  catarrh  sometimes 
occurs  in  combination  with  a  more  discrete  eruption  of 
larger  pustules. 

The  typical  eczema-pustu/c  or  phlyctenule  is  circular  in 
form,  and,  when  recent,  appears  as  a  small,  reddish-gray 
elevation  capped  with  a  layer  of  smooth  epithelium.  Jt 
is  surrounded  by  a  zone  of  marked  conjunctival  injection. 
On  the  second  day  after  its  appearance  the  covering  sepa- 
rates and  is  replaced  by  a  small,  circular  mass  of  gray  or 
yellow  necrotic  tissue  (Plates  17  and  18).  The  yellow 
spot  gradually  encroaches  on  the  body  of  the  pustule,  so 
that  the  larger  ones  are  eventually  converted  into  small 
round  ulcers,  only  slightly  raised  above  the  level  of  the 
conjunctiva.  As  the  healing  process  goes  on  the  pustules 
become  more  and  more  flattened,  the  inflammatory  zone 
contracts,  and  the  site  of  the  ulcer  is  covered  with  new 
epithelium.  The  disease  lasts  from  one  to  two  weeks  and 
never  attacks  the  sclera. 

The  cornea  is  very  often  affected,  either  alone  or  in 
association  with  the  conjunctiva.  In  some  cases  only  the 
cornea  is  attacked  in  one  eye,  and  the  conjunctiva,  without 
the  cornea,  in  the  other.  The  cornea  is  most  liable  to  be 
involved  in  the  multiple  form,  characterized  by  the  pres- 
ence of  innumerable  granular  elevations. 

As  in  other  parts  of  the  body,  the  eczema  is  distin- 
guished by  its  occurrence  in  successive  crops;  pustules 
in  all  stages  of  development  are  seen  at  the  same  time 
with  the  scars  of  a  former  attack. 

The  corneal  eczema  may  be  primary,  or  secondary  to 
marginal  eczema  of  the  conjunctiva.     The  secondary  form 


132  EXTERNAL  DISEASES  OF  THE  EYE. 

is  observed  as  a  (1)  simple  marginal  irritation,  to  be  dis- 
cussed later;  (2)  the  excavated  or  funnel-shaped  uleer ; 
(3)  fascicular  keratitis;  (4)  phlyctenular  (eczematous) 
marginal' pannus ;  and  (5)  marginal  ring-ulcer  (annular 
ulcer). 

Eczema  of  the  conjunctiva  causes  little  discomfort,  as 
the  general  appearance  of  the  patient  shows;  he  usually 
seeks  relief  for  a  slight  stinging-pain  during  the  eruptive 
stage  and  the  feeling  as  if  the  eye  contained  a  foreign 
body ;  occasionally  the  lids  are  glued  together  in  the 
morning. 

The  diagnosis  is  readily  made  if  it  is  borne  in  mind 
that  eczema  preferably  attacks  young  subjects,  while  car- 
cinoma, which  in  its  initial  stage  resembles  an  eczema- 
pustule  and  also  begins  at  the  corneal  margin,  occurs  only 
in  elderly  persons.  Another  fundamental  difference  is, 
that  carcinomatous  nodules  never  undergo  the  rapid  de- 
generation which  puts  a  speedy  end  to  the  life  of  an  eczema- 
pustule.  Cancer  displays  the  general  characters  of  a  solid 
growth,  and  ulceration,  if  it  occurs  at  all,  is  delayed  a  much 
longer  time.  Nevertheless  I  have  seen  several  cases  of 
carcinoma  which  were  at  first  diagnosed  and  treated  as 
eczema  by  the  family  physician,  and  the  loss  of  precious 
time  occasioned  by  this  error  led  to  a  fatal  termination. 

Seleritis,  which  is  characterized  by  the  formation  of  fiat, 
circular  elevations  from  3  to  5  mm.  in  diameter,  may  in 
its  initial  stage  be  confounded  with  eczema.  An  old  case 
of  seleritis  can  be  recognized  by  the  slate-colored  tint  of 
the  sclera  remaining  from  an  earlier  attack,  while  in  recent 
cases  the  diagnosis  is  established  by  observing  that  the 
epithelial  covering  of  the  nodules  is  intact  and  does  not 
undergo  necrotic  change.  The  scleritic  focus,  moreover, 
is  surrounded  by  a  bluish  injection,  while  in  eczema  the 
congestion  is  of  the  conjunctival  type  and  is  more  super- 
ficial. Finally,  there  is  much  more  pain,  both  spontane- 
ous and  on  pressure,  in  seleritis. 

A  superficial  observer  might  mistake  a  case  of  marginal 
eczema  of  the  conjunctiva  for  spring-conjunctivitis;  but 


DISEASES  OF  THE  CONJUNCTIVA.  133 

the  nodules  in  the  latter  disease  do  not  begin  to  degenerate 
at  the  top  like  eczema-pustules.  In  doubtful  cases  it  is 
only  necessary  to  remember  that  circumscribed  eruptions 
and  their  ulcers  are  always  approximately  circular  in 
shape. 

The  prognosis  in  simple  conjunctival  eczema  is  always 
favorable,  whether  the  pustules  be  large  or  small.  The 
disease  is  never  dangerous,  although  it  may  occasion  a 
good  deal  of  discomfort  if  it  is  protracted.  As  an  index 
of  the  scrofulous  habit  or  debilitated  condition  of  the 
patient,  it  is  always  of  some  significance,  because  the 
cornea  in  such  cases  may  at  any  time  become  involved  and 
endanger  the  integrity  of  the  visual  apparatus. 

The  treatment  is  quite  simple.  The  pustules  might 
with  propriety  be  allowed  to  heal  spontaneously  ;  but  it  is 
better  to  assist  the  healing  process  by  dusting  the  affected 
areas  with  powdered  calomel,  as  a  more  radical  cure  is 
thereby  effected  and  the  danger  of  recurrence  is  reduced  to 
a  minimum.  For  the  latter  reason  the  treatment  should 
be  continued  for  two  weeks  after  the  ulcers  have  healed. 

Experience  has  taught  the  value  of  the  following  pre- 
cautions in  the  use  of  calomel  as  a  dusting-powder  :  It 
should  not  be  employed  if  there  is  a  recent  corneal  lesion 
oi-  any  general  irritative  condition  ;  hence  it  is  contrain- 
dicated  in  "catarrh  with  swelling."  The  drug  must  be 
perfectly  pure  and  as  finely  powdered  as  possible  by  being 
sifted  through  a  cloth.  The  applications  should  be  made 
with,  a  camel's-hair  brush  (the  excess  being  removed  by 
tapping  against  the  finger),  at  the  same  hour  every  day, 
either  directly  on  the  pustule  or  on  the  lower  retrotarsal 
fold.  If  the  patient  is  taking  large  doses  of  potassium 
iodid  at  the  time  of  treatment  calomel  is.contraindicated, 
as  the  caustic  effect  on  the  conjunctiva  would  be  too  great. 
Iodin  is  eliminated  by  the  conjunctiva  as  by  other  mucous 
membranes — that  of  the  nose,  for  instance  (hence  potassium- 
iod id  catarrh  of  the  conjunctiva,  nose,  etc.) — and  combines 
with  calomel  to  form  iodids  of  mercury,  which  act  as 
severe  caustics.     I  have  seen  eschars  due  to  this  chemical 


134  EXTERNAL   DISEASES  OF  THE  EVE. 

reaction  as  thick  as  a  diphtheritic  membrane  covering  the 
entire  conjunctiva. 

If  eczema  is  complicated  with  severe  catarrh,  the  secre- 
tion must  be  controlled  by  painting  the  conjunctiva  with 
;i  1-2  per  cent,  solution  of  silver  nitrate  before  calomel  is 
applied  ;  but  if  there  is  much  inflammatory  swelling,  the 
irritation  should  first  be  allayed  by  the  application  of  hot 
compresses  steeped  in  lead-water. 

Atropin  is  usually  quite  unnecessary  in  conjunctival 
eczema,  as  the  pain  is  not  severe  enough  to  demand  its 
use  [a  warm  collyrium  of  boric  acid  is  valuable. — Ed.]. 

The  local  applications  should  always  be  supplemented 
by  genera]  medicinal  treatment  of  the  fundamental  disease 
and  by  tonics  to  improve  the  patient's  general  health. 
This  matter  will  be  referred  to  again  in  connection  with 
the  treatment  of  corneal  eczema.  [In  all  these  cases  the 
rhinopharynx  is  always  more  or  less  diseased  and  requires 
assiduous  care. — Ed.] 

Other  localized  eruptions  are  rare  in  the  conjunctiva 
compared  with  eczema ;  we  may  mention,  however,  pem- 
phig a s,  variola,  and  acne.  In  rare  instances  macular  and 
papular  syphilides,  pityriasis,  psoriasis,  ichthyosis,  etc.,  are 
met  with,  usually  as  forming  part  of  a  general  process. 

8.  Pemphigus. 

Pemphigus  gradually  leads  to  the  condition  formerly 
termed  "essential  shrinking  of  the  conjunctiva."  The 
conjunctival  sac  in  the  course  of  years  becomes  completely 
obliterated,  the  lids  are  immovably  fixed  to  the  eyeball, 
and  the  cornea,  owing  to  the  loss  of  nictitation,  becomes 
ulcerated  and  thrown  into  folds.  Bulla?  are  rarely  seen, 
owing,  probably,  to  the  delicate  structure  of  the  mem- 
brane;  instead,  the  conjunctiva  is  covered  with  gray 
patches,  deprived  of  epithelium  and  covered  with  a  lar- 
daceous  secretion,  which  later  arc  converted  into  cicatrices, 
while  fresh  lesions  appear  in  other  situations.  In  some 
cases  the   mucous  membrane  of  the   mouth   is  similarly 


DISEASES  OF  THE  CONJUNCTIVA.  135 

affected,  or  there  is  pemphigus  of  the  general  integument 
to  indicate  the  nature  of  the  conjunctival  lesion. 

The  prognosis  is  gloomy,  as  no  effective  treatment  has 
as  yet  been  discovered. 

9.  Variola. 

There  is  grave  danger  that  the  pustules  about  the  lower 
corneal  margin  may  give  rise  to  a  secondary  corneal  affec- 
tion in  the  form  of  marginal  ulcers  or  deep  purulent  in- 
filtration, resulting  in  perforation-staphyloma,  purulent 
iridochoroiditis,  and  panophthalmia.  These  sequelae, 
which  are  not  noticed  until  the  conjunctival  disease  has 
subsided,  are  the  most  frequent  causes  of  blindness  after 
small-pox. 

10.  Acne. 

Acne  may  produce  nodules  about  the  corneal  margin 
which  closely  resemble  eczema-pustules.  The  eruption  is 
frequently  seen  on  the  cornea  of  patients  the  subjects  of 
aggravated  acne  rosacea.  The  infiltration  resembles  that 
seen  in  eczema  ;  it  is  gray  in  color,  slightly  raised  above 
the  surrounding  level,  is  more  persistent,  and  leaves  a  more 
pronounced  opacity  than  the  eczema-pustule.  T  have 
known  it  to  produce  almost  complete  opacity  of  both 
corneas  in  the  course  of  years. 

11.   Scleritis. 

In  scleritis  I  have  sometimes  seen  the  conjunctiva  in 
the  diseased  area  dotted  with  a  number  of  round,  flat 
nodules,  from  1  to  2  mm.  in  diameter,  which  were  dis- 
tinguished from  eczema-pustules  by  the  absence  of  con- 
junctival congestion  and  by  the  fact  that  they  did  not 
degenerate,  but  persisted  for  days  and  weeks  and  were 
gradually  absorbed.  Under  the  microscope  they  were 
seen  to  consist  of  masses  of  growing  connective  tissue, 
fairly  rich  in  cellular  elements.  I  have  never  been  able 
satisfactorily  to  explain  the  relation  of  these  nodules  to  the 
scleritic  process. 


136  EXTERNAL    DISEASES  OF  THE  VAE. 

Finally,  we  must  include  among  the  circumscribed  in- 
flammatory  processes  in  tho  conjunctiva  the  various  forms 

of  infectious  granular  tumors,  chief  among  which  is 

12.   Tuberculosis. 

Tuberculosis  is  always  chronic,  and  occurs  either  inde- 
pendently or  in  association  with  lupus  of  the  face.  In 
nearly  every  case  the  nature  of  the  disease  manifests 
itself  by  swelling,  and  occasionally  by  cheesy  and  puru- 
lent degeneration  of  the  preauricular  and  submaxillary 
lymph-glands.  Sometimes  the  process  is  purely  local,  or 
at  least  no  signs  of  tuberculosis  are  found  in  other  organs 
of  the  body.  In  other  instances  the  patient  exhibits 
signs  of  a  general  tubercular  infection  in  lungs,  lymphatic 
glands,  joints,  etc.  Occasionally  the  process  begins  in  the 
nose  and  the  infection  is  carried  to  the  eye  through  the 
lachrymal  duct.  In  the  conjunctiva  it  appears  first  as  a 
more  or  less  circumscribed  focus  of  tubercular  infiltration, 
or  as  a  single  nodule,  or  the  tubercles  are  scattered  over 
a  larger  area.  The  tuberculous  growth  is  more  or  less 
completely  enclosed  in  a  capsule  of  granulation-tissue, 
which  materially  increases  the  extent  of  the  focus  ;  neither 
tubercular  nodules  nor  bacilli  are  to  be  found  in  the  ex- 
cised growth.  These  are  only  found  in  the  deeper  layers 
of  the  hypertrophied  tissue,  if  they  are  found  at  all  :  the 
bacilli  are  never  present  in  large  numbers  any  more  than 
in  other  forms  of  chronic  tuberculosis. 

The  tubercles  rapidly  become  cheesy  and  break  down, 
and  the  conjunctiva  becomes  covered  with  tuberculous 
ulcers  with  purulent  or  cheesy  floors  and  surrounded  by 
granulation-tissue.  In  the  intervals  between  the  ulcers, 
which  may  be  quite  numerous  if  the  process  becomes 
extensive,  miliary  tubercles  are  occasionally  seen,  and 
sometimes  true  follicles,  resembling  trachomatous  granu- 
lations. In  protracted  cases  the  entire  palpebral  conjunc- 
tiva of  both  lid-  eventually  becomes  diseased,  gradually 
the  process  encroaches  on  the   pupillary  region,  and  the 


DISEASES  OF  TBE  CONJUNCTIVA.  137 

cornea  may  be  completely  obscured  by  the  formation  of 
a  dense  pan nu s.  The  scars  which  sometimes  form  in  the 
conjunctiva  often  produce  a  condition  which  closely  sim- 
ulates trachoma,  especially  if  both  eyes  arc  affected,  as 
occasionally  happens. 

Pain  is  usually  inconsiderable  and  depends  chiefly  on 
the  accompanying  catarrh  ;  later,  if  keratitis  develops,  the 
patients  may  suffer  some  discomfort. 

The  diagnosis  is  based  on  the  swelling  of  the  pre- 
auricular lymph-gland  and  on  the  formation  of  ulcers 
with  purulent  floors,  phenomena  which  do  not  occur  in 
trachoma.  Under  certain  conditions,  if  the  process  is 
confined  to  the  tarsal  region,  a  round  nodule  closely  re- 
sembling a  chalazion  may  be  formed  on  the  lid ;  even 
Baumgarten  once  mistook  a  tubercular  nodule  in  this  situ- 
ation for  a  chalazion.  In  doubtful  cases  the  diagnosis 
should  be  confirmed  by  inoculation,  if  tubercle-bacilli 
cannot  be  demonstrated. 

The  prognosis  in  all  cases  is  very  grave,  as  the 
growth  may  recur  after  the  most  careful  excision.  If  the 
focus  is  very  small,  a  cure  may  be  effected  by  the  radical 
removal  of  the  proliferations ;  but  if  there  is  general 
involvement  of  the  conjunctiva  and  of  the  lids,  it  is  dif- 
ficult to  arrest  the  process.  In  the  case  of  two  young 
men  of  marked  tubercular  habit  who  came  to  me  late  in 
the  disease,  the  sight  of  both  eyes  was  destroyed  ;  and  in 
another  case,  that  of  a  young  woman,  one  eye  became  en- 
tirely blind  and  the  other  very  nearly,  in  the  course  of 
years. 

The  treatment  consists  in  the  thorough  removal,  as 
far  as  possible,  of  the  diseased  tissues  by  operative  means, 
and  in  the  application  of  iodoform.  Unfortunately  the 
drug  cannot  always  be  brought  into  close  contact  with 
the  tuberculous  nodules.  I  have  never  seen  any  good 
results  follow  the  use  of  either  the  old  or  the  new  (modi- 
fied) tuberculin  preparation  ;  the  latter  was  tried  lately  in  a 
case  with  lupus  of  the  face,  and  neither  the  tuberculous 
nor  the  lupous  process  showed  any  improvement.     Gen- 


138  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  1 6. 

a.  Chaff-particle  at  the  corneal  margin.  The  patient,  a  peasant-girl, 
does  not  know  how  long  the  foreign  body  has  been  in  the  eye,  but  the 
vascular  development  of  the  cornea  shows  that  it  must  have  been  there 
for  some  time. 

6.  Pterygium  in  an  elderly  man.  It  has  spread  over  the  cornea  gradu- 
ally during  the  last  few  months.  The  obliteration  of  the  plica  semi- 
lunaris is  well  shown. 

eral  constitutional  remedies  should,  of  course,  be  added 
to  the  local  treatment. 

13.   Syphilomata  and   Leprosy. 

Syphilomata  and  leprosy  are  occasionally  met  with,  the 
former  very  rarely.  In  leprosy  the  region  about  the 
corneal  margin  becomes  the  seat  of  yellowish,  semitrans- 
parent tubercles,  witli  few  blood-vessels,  which  may  pene- 
trate into  the  sclera  or  spread  over  the  surface  of  the 
cornea.  The  breaking  down  of  the  tubercles  is  followed 
by  extensive  tissue-destruction.  In  addition,  the  tubercles 
appear  in  the  iris  and  produce  iritis  and  cyclitis,  which 
cause  further  injury  to  the  eye. 


INJURIES  OF  THE  CONJUNCTIVA. 

1.  Foreign  bodies  are  frequently  found  in  the  con- 
junctival sac.  A  small  body  usually  lodges  on  the  inner 
surface  of  the  upper  lid,  near  the  margin  ;  larger  ones 
often  find  their  way  under  the  upper  retrotarsal  fold, 
where  they  may  remain  for  some  time  and  give  rise  to 
granulations  and  catarrhal  secretion.  The  fold  in  such 
cases  must  be  carefully  scraped  out  and  cleansed  with  a 
probe.  Agricultural  patients  occasionally  present  them- 
selves with  a  particle  of  chaff  (Plate  16,  a)  or  the  wing 
of  an  insect  firmly  embedded  near  the  corneal  margin. 
The  concave  border  of  the  foreign  body  is  usually  directed 
toward  the  eye,  so  that  it  get-  a  firm  hold  of  the  tissues 
and  often  remains  for  weeks,  and  may  cause  .new  blood- 


Tab.  16. 


Liih.  Anst  F.  Reichhold.  München. 


DISEASES  OF  THE  CONJUNCTIVA.  139 

vessel  formation  and  even  granulations.     Sometimes  it  is 
found  on  the  eornea  itself. 

2.  Ecchymoses  of  the  conjunctiva  (hyphsema 
conjunctivae,  Plate  14,  b)  are  quite  common,  either  as  t lie* 
result  of  injuries,  such  as  scratches  or  cut-wounds,  or  from 
stasis  of  the  blood  during  a  paroxysm  of  whooping- 
cough,  or  ordinary  cough  in  elderly  people  with  weak 
vessel-walls.  It  has  been  observed  especially  in  persons 
who  are  the  subjects  of  marked  arteriosclerosis  with  or  with- 
out nephritis,  and  who  usually  die  of  apoplexy  ;  hence  the 
phenomenon  is  significant  from  a  diagnostic  point  of  view. 
Wounds  of  the  conjunctiva  should  be  closed  with  sutures 
as  soon  as  possible. 

3.  Burns,  caused  by  molten  lead  or  iron,  hot  ashes, 
etc.,  or  by  acids  and  alkaline  lyes,  and  particularly  by 
slaked  or  unslaked  lime  (mortar),  are  among  the  common- 
est accidents.  The  usual  seats  are  the  lower  portion  of 
the  conjunctival  sac  and  the  lower  segment  of  the  cornea 
(Plate  19).  The  epithelium  is  destroyed  and  the  necrotic 
tissue  appears  grayish  or  bluish-white,  while  the  adjacent 
conjunctiva  is  intensely  swollenand  inflamed,  and  occasion- 
ally suffused  with  blood.  Burns  on  the  cornea  give  rise  to 
similar  whitish  spots ;  these  soon  lose  their  epithelial  cov- 
ering (Plate  19,  6),  ulcers  are  formed,  and  a  cicatricial 
opacity  results,  which,  if  situated  in  the  center,  may  in- 
terfere seriously  with  visual  acuity.  In  the  conjunctiva 
the  injury  is  followed  by  cicatricial  contractions,  shorten- 
ing of  the  mucous  membrane,  general  shrinking  of  the 
conjunctival  sac,  and  the  development  of  Symblepharon. 

In  the  cornea  the  eroded  area  sometimes  becomes  cov- 
ered by  a  process  of  conjunctiva,  forming  a  so-called 
Pseudopterygium. 

Treatment. — The  ultimate  effects  of  a  lime-burn  are 
much  more  serious  than  appears  at  the  first  glance,  and 
great  care  is  therefore  necessary  in  the  treatment.  The 
injured  eye  must  not  be  washed  with  water,  as  such  a  pro- 
ceeding would  dissolve  more  of  the  caustic  material  and 
diffuse  it  over  the  conjunctival  sac.     The  cleansing  is  best 


140  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  17. 

Eczema  of  the  Conjunctiva,  associated  with  Severe  Eczema  of  the 
Face. — An  ill-nourished  factory-girl,  15  years  old,  with  sallow,  puffy 
face,  afflicted  with  chronic  rhinitis,  eczema  of  the  nose  and  fact-,  and 
eezernatous  catarrh  of  both  eyes,  with  considerable  secretion.  At  the 
nasal  border  of  the  cornea,  in  the  right  eye,  a  pustule  is  seen,  situated 
partly  on  the  conjunctiva  and  partly  on  the  cornea.  In  the  left  eye 
there  is  a  single  pustule  on  the  bulbar  conjunctiva,  to  the  temporal  side 
of  the  cornea,  the  margin  of  which  is  also  beset  with  minute  pustules 
(not  seen  in  the  picture).  The  facial  eczema  was  subjected  to  suitable 
treatment,  the  conjunctiva  painted  with  silver  nitrate,  and  later  dusted 
with  calomel.  The  patient  was  subjected  to  diaphoresis.  After  a  two 
months'  course  of  treatment,  which  was  marked  by  many  relapses,  a 
complete  cure  was  effected  without  injury  to  the  eyes. 


effected  with  a  brush  clipped  in  oil,  after  which  a  concen- 
trated solution  of  sugar,  which  combines  with  lime  to  form 
an  insoluble  compound,  may  be  instilled  into  the  eye.  If 
the  burn  was  caused  by  an  acid  or  by  an  alkali,  use  a 
substance  which  will  neutralize  the  caustic  agent.  To 
allay  the  pain  and  isolate  the  injured  tissue  as  much  as 
possible,  vaselin  containing  1  per  cent,  of  atropin  may  be 
rubbed  in  ;  this  also  has  a  tendency  to  prevent  adhesions 
between  the  lids  and  bulb.  But  it  is  not  always  pos- 
sible to  prevent  the  development  of  Symblepharon,  and 
an  operation  subsequently  becomes  necessary. 

PTERYGIUM. 

This  anomaly  consists  of  a  triangular  rlap  of  conjunc- 
tiva, which  by  a  very  gradual  process,  lasting  months  or 
years,  encroaches  on  the  cornea  either  from  the  nasal  or 
the  temporal  side  (Plates  16,6,  and  26,  a).  In  severe 
cases  the  growth  eventually  covers  the  pupil  and  causes 
permanent  diminution  of  vision.  AVherever  the  ptery- 
gium becomes  adherent  to  the  cornea  a  permanent  super- 
ficial opacity  remains. 

The  pterygium  develops  from  a  pinguecula,  a  yellowish 
elevation  not  infrequently  seen  in  elderly  people  on  either 
the  nasal  or  the  temporal  side  of  the  cornea.     It  is  often 


Tab.   17. 


m 


*f 


V 


-vom. 


l.ith.  Ans/  F.  Reuiihold.  München . 


DISEASES  OF  THE  CONJUNCTIVA.  141 

caused  by  exposure  to  wind  and  dust.  The  yellow  color, 
which  gave  origin  to  the  name,  is  not  due  to  fat,  but  to 
hyaline  degeneration  and  an  overgrowth  of  elastic  fibers. 
The  mechanism  involved  in  the  movement  of  the  pinguec- 
ula  and  adjacent  conjunctiva  toward  the  cornea  is  not  well 
understood. 

Two  forms  of  pterygium  are  distinguished,  the  pro- 
gressive and  the  stationary.  The  latter  is  smooth  and  light 
in  texture,  non-inflammatory,  with  a  flattened,  fibrous 
apex  ;  it  gives  little  pain.  The  progressive  pterygium, 
on  the  other  hand,  is  succulent  and  inflamed  ;  the  apex  or 
the  entire  central  border  is  swollen  and  grayish-red  in 
color.  A  large  pterygium  exerts  a  good  deal  of  traction 
on  the  conjunctiva,  so  that  the  semilunar  fold  is  often  ob- 
literated (Plate  16,  b). 

The  sequels  of  pterygium  are  conjunctival  catarrh,  de- 
formity, and  eventually  diminished  vision  by  obscuration 
of  the  pupil  or  diplopia  from  motor  disturbances  in  the 
globe. 

The  treatment  consists  in  operative  removal  of  the 
growth  and  reposition  of  the  conjunctiva  ;  cauterization 
is  usually  of  no  avail.  The  growth,  however,  is  liable  to 
recur  even  after  radical  surgical  removal. 


TUMORS  OF  THE   CONJUNCTIVA. 

Benign  Tumors. — The  commonest  form  is  the  der- 
moid  growth  (Plate  11,  a  and  b).  The  cornea  is  usually 
involved  to  a  greater  extent  than  the  illustrations  show. 
The  tumor  is  always  congenital,  and  chiefly  troublesome 
on  account  of  the  deformity  it  produces.  Its  usual  seat  is 
the  external  or  the  inferior  margin  of  the  cornea.  Struct- 
urally it  is  neither  more  nor  less  than  a  piece  of  aberrant 
skin,  supplied  with  hairs  and  sebaceous  and  sudorific 
glands.  Associated  with  it  we  often  find  malformation  of 
the  lids,  iris,  etc. 

In  removing  the  tumor  great  care  is  necessary  to  avoid 
making  an  opening  in  the  cornea. 


142  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  1 8. 

a.  Marginal  eczema-pustule  in  a  scrofulous  boy,  12  years  old ;  three 
days  after  the  beginning  of  the  disease. 

b.  Epithelioma  involving  both  cornea  and  conjunctiva,  in  a  man,  aged 
36  years.  The  tumor  lias  been  growing  steadily  for  three  years  ;  but  the 
patient  felt  no  inconvenience  until  quite  recently,  when  it  began  to 
cause  itching  and  stabbing-pains  and  some  diminution  of  vision.  The 
growth  is  not  painful  on  pressure.  The  adjacent  portion  of  the  cornea 
is  thick  and  opaque,  its  surface  rough  and  uneven  ;  the  rest  of  the  cornea 
is  covered  with  a  cloudy  and  highly  vascular  film,  so  that  direct  inspec- 
tion of  the  eye  is  impossible.  Vision  is  practically  abolished,  the  move- 
ments of  the  hand  being  discerned  only  at  a  very  short  distance.  Enu- 
cleation. Examination  shows  that  the  cornea  is  largely  involved,  and 
even  the  sclera  has  been  attacked  by  the  tumor. 

Simple  polypi  (small  fibromas)  occur  rarely ;  their 
favorite  seat  is  the  inner  canthus.  Papillomata  arc 
occasionally  seen  in  the  same  situation. 

Malignant  tumors  include  carcinoma  (epithelioma) 
and  sarcoma.  Both  tumors  preferably  begin  at  the  cor- 
neal margin.  Epithelioma  originates  as  a  small,  non-pig- 
mented,  flat  elevation,  not  unlike  an  eczema-pustule,  which 
for  a  long  time  retains  its  superficial  character,  but  eventu- 
ally becomes  larger  and  penetrates  more  deeply  into  the 
subconjunctival  tissue  (Plate  18,  6).  While  cancerous 
growths  are  seated  on  a  broad  base  and  tend  to  spread 
superficially,  the  tendency  of  a  sarcoma  is  rather  to  grow 
in  height,  overhanging  the  cornea  without  involving  its 
structure.     Sarcoma   is  usually  pigmented. 

Both  carcinoma  and  sarcoma  are  exceedingly  malignant 
and  demand  immediate  radical  excision,  to  protect  both 
the  eye  and  the  life  of  the  patient.  If  the  tumor  is  firmly 
embedded  in  the  tissues  of  the  eye,  enucleation  is  unavoid- 
able. 


Tab.  18. 


J1 


J.äh.Anst  /•'  Hoichhold.  Manchen 


DISEASES  OF  THE  CORNEA.  143 

DISEASES  OF  THE  CORNEA. 
A.  DIFFUSE  INFLAMMATIONS. 

i.  Parenchymatous  Keratitis  (Interstitial  or  Diffuse 
Keratitis ) . 

This  disease  is  important,  not  so  much  on  account  of  its 
frequency  as  of  the  grave  symptoms  to  which  it  gives 
rise.  The  great  majority  of  cases  (90  per  cent.)  occur  in 
children  between  the  ages  of  five  and  sixteen.  The  course; 
of  the  disease  has  been  so  admirably  described  by  Horner1 
that  it  seems  to  us  we  cannot  do  better  than  quote  his 
exact  words  : 

"In  these  children  a  faint,  gray  haze,  accompanied  by 
slight  ciliary  congestion,  slowly  creeps  into  the  periphery 
of  the  cornea.  At  first  it  occupies  a  narrow  baud  along 
the  margin  ;  but  gradually  it  includes  wider  portions  of 
the  periphery  and  sends  out  tongue-like  processes  toward 
the  center  (see  Plate  28,  c),  which  soon  coalesce  and  cover 
the  entire  marginal  zone  with  a  cloudy  film,  leaving  only 
the  central  portion  free.  The  lids  are  spasmodically 
closed,  and  when  we  force  them  apart  we  observe  that  the 
surface  of  the  cornea  is  cloudy  and  the  epithelium  has  a 
steamy,  stippled  appearance  (in  rare  cases  it  is  puckered 
into  folds),  as  in  cases  of  increased  intraocular  pressure. 
"With  lateral  illumination  the  stripe-like  and  net-like 
opacities  are  seen  to  occupy  the  deeper  layers  of  the  mem- 
brane. The  film  gradually  advances  from  all  directions 
toward  the  center,  where  it  contracts  and  increases  more 
and  more  in  density,  forming  a  serious  obstacle  to  vision, 
while  pari  passu  the  marginal  zone  begins  to  regain  its 
transparency.  Now  the  central  opacity  gradually  begins 
to  change,  and  the  surface  relaxes  and  breaks  up,  show- 
ing areas  of  greater  transparency  among  the  gray  spots. 
The  vascular  changes  vary  widely  during  this  process  of 
migration.  In  some  cases  the  centripetal  migration  is  not 
followed  by  any  pathologic  changes  in   the  blood-vessels; 

1  Horner,  "Die  Krankheiten  des  Anges  im  Kindesalter,"  Handb.  der 
Kinderkrankheiten,  5  Bd.,  ii.  Abt.,  p.  320. 


144  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  19. 

a.  Lime-burn  of  the  conjunctiva  and  cornea,  recent,  in  a  boy,  13 
years  old.  The  injury  was  caused  by  the  explosion  of  a  bottle  which 
the  patieut  was  filling  with  water  aud  uuslaked  lime.  The  skiu  of  the 
lids,  on  the  right,  shows  the  marks  of  glass  fragments.  The  conjunctiva 
of  the  upper  and  lower  lid  is  badly  excoriated  ;  also  the  bulbar  con- 
junctiva below  the  cornea  and  the  lower  segment  of  the  cornea  itself, 
which  is  dim  and  bluish-white.  Satisfactory  cure  was  obtained  with 
practically  normal  vision,  although  a  rather  dense  cicatricial  opacity  re- 
mained about  the  lower  corneal  margin  and  the  conjunctiva  covering 
the  lower  retrotarsal  fold  was  somewhat  shortened. 

6.  Lime-burn  of  the  conjunctiva  and  cornea,  of  longer  standing 
than  the  preceding,  in  a  mason,  18  years  old.  A  week  ago,  while 
the  patient  was  mixing  mortar  with  lime  that  had  been  slaked  two 
days  before,  some  of  the  material  entered  the  left  eye.  The  eschar 
is  seen  in  process  of  separation,  and  the  corresponding  spot  on  the 
cornea  has  lost  its  epithelium  and  is  surrounded  by  a  gray  border.  The 
center  of  the  injured  spot  is  slightly  depressed  from  the  loss  of  tissue. 
Healing  was  followed  by  only  slight  scar-formation  and  vision  was  not 
diminished. 

in  others  a  few  small  vessels  appear  in  the  deeper  layers 
of  the  cornea,  but  not  until  some  time  after  the  formation 
of  the  central  opacity.  In  a  few  rare  cases,  however,  a 
very  characteristic  vessel-formation  is  observed  to  accom- 
pany the  advance  of  the  process  from  the  sclera  into  the 
cornea.  Short,  densely  packed  blood-vessels,  terminating 
abruptly  at  the  center,  appear  to  push  the  opacity  before 
them  and  in  a  sense  constrict  the  corneal  field.  These 
vessels  are  sometimes  so  thickly  crowded  that  they  look 
like  an  ecchymosis. 

"The  corneal  disease  does  not  end  with  the  completion 
of  the  centripetal  migration  and  breaking  up  of  the  cen- 
tral opacity.  Irregular  gray  spots  and  nebula)  make  their 
appearance  in  the  substance  of  the  cornea  and  combine 
with  the  resolution  of  the  central  opacity  to  give  the 
membrane  a  speckled  appearance.  This  secondary  stage 
is  sometimes  interpreted  as  a  primary  corneal  lesion,  and 
the  special  name  keratitis  punctata  is  given  to  it.  The  error 
is  readily  explained  by  the  fact  that  the  patients  do  not 


Tab.   19. 


^ 


if 


Ltih.Anst  F.  Reichhold,  München. 


DISEASES  OF  TUE  CORNEA.  145 

usually  present  themselves  for  treatment  until  after  the 
centripetal   migration   is  completed. 

"  When  iritis  occurs  as  a  complication  the  precipitates 
on  the  posterior  lamina  of  the  cornea  and  the  secondary 
changes  in  the  more  anterior  portions  of  the  membrane 
tend  to  accentuate  the  punctate  appearance  of  the  opacity 
and  thus  form  another  source  of  error.  In  about  :j()  per 
cent,  of  all  cases  of  interstitial  keratitis  the  deep  struct- 
ures of  the  eye  become  involved  early  in  the  course  of 
the  disease;  but  in  most  cases  this  complication  appears 
much  later.  Iritis  usually  takes  the  serous  form  ;  it  is 
attended  with  the  deposition  of  heavy  precipitates  on  the 
posterior  lamina  of  the  cornea  and  ligamentum  pectina- 
tum,  slight  exudation  into  the  pupil,  and  variable  pressure- 
symptoms — usually  subnormal  tension.  As  serous  iritis 
itself  is  a  form  of  «reitis,  we  are  often  able,  after  the  cen- 
ter of  the  cornea  has  cleared  up,  to  establish  the  exist- 
ence of  opacities  in  the  vitreous,  equatorial  foci  of  cho- 
roiditis, and  uveal  neuritis;  we  may  find  polar  and  poste- 
rior cortical  cataract — in  short,  all  the  signs  of  a  diffuse 
morbid  process,  which  from  its  conspicuous  feature  has 
been  called  diffuse  keratitis,  but  is  very  often  a  panoph- 
thalmia. 

"The  disease  usually  affects  both  eyes,  the  second  being 
attacked  days,  weeks,  or  even  months  after  its  fellow.  I 
myself  have  been  able  to  establish  bilateral  involvement 
in  80  per  cent,  of  my  cases,  in  spite  of  the  obvious  fact 
that  the  patient  hails  the  appearance  of  disease  in  the  sec- 
ond eye  as  a  proof  of  inefficient  treatment  and  seeks  ad- 
vice elsewhere.  It  is  always  advisable  to  predict  the 
probable  occurrence  of  the  disorder  in  the  other  eye,  and 
to  warn  the  patient  that  it  is  very  apt  to  run  a  slow  and 
tedious  course.  The  most  favorable  cases  last  from  six  to 
eight  weeks  ;  secondary  opacities,  iritic  complications,  and 
their  consequences  protract  the  duration  of  the  disease  to 
months  and  years.  Relapses  are  frequent,  even  after  long 
intervals  of  freedom  from  the  disease.  These  relapses  do 
not,  as  a  rule,  exhibit  the  same  character  as  the  original 

10 


14()  EXTERNAL  DISEASES   OF  THE  EYE. 

attack  ;  the  participation  of  the  sclera  is  more  pronounced 
or  a  true  scleritis  develops;  and  the  corneal  haze  is  not  so 
diffuse,  but  appears  in  patches,  while  the  vascular  changes 
in  the  superficial  and  deep  layers  are  more  irregular." 

The  ultimate  fate  of  the  corneal  macula?  varies  widely. 
In  some  cases  transparency  is  completely  regained  ;  in 
others,  marked  by  frequent  relapses,  the  center  is  irre- 
mediably obscured  by  fine,  nebular  opacities  and  vision 
is  permanently  injured.  In  almost  every  case  of  inter- 
stitial keratitis  minute  vessels  can  be  detected  with  a  loupe 
and  lateral  illumination,  or  with  the  ophthalmoscope  and 
direct  light.  They  can  be  seen  twenty  years  after  an 
attack,  and  may  be  utilized  as  a  diagnostic  sign  of  syphilis. 

The  cause  in  two-thirds  of  the  cases  is  hereditary 
syphilis,  and  the  classical  signs  of  this  condition  should 
always  be  looked  for  ;  they  are  :  Flat  upper  jaws,  sunken 
nasal  bridge,  scars  at  the  angles  of  the  mouth,  and  Hutchin- 
son's teeth,  characterized  by  diminished  size  with  fairly 
good  enamel  and  shapely  outline,  and,  usually,  wide  inter- 
vals, especially  between  the  incisors.  The  central  incisors 
of  the  upper  jaw  are  wedge-shaped  at  the  expense  of  the 
free  cutting-surface,  which  is  often  marked  with  a  small 
circular  notch.  The  significance  of  the  deformity  is 
limited  to  the  permanent  teeth.  AVe  also  look  for  ulcers 
or  scars  in  the  palate,  for  tissue-destruction  of  the  pillars 
of  the  fauces,  or  adhesions  of  these  structures  to  the 
pharyngeal  wall.  Deafness  not  infrequently  develops  in 
the  later  stages  of  the  disease;  the  cervical  glands  are  en- 
larged ;  there  are  chronic  periostitis  of  the  tibia?  and  pain- 
less synovial  effusions  in  the  knee-joint.  Upon  inquiring 
into  the  family  history  we  learn  of  a  large  mortality 
among  the  children,  and  of  abortions  and  stillborn  infants. 
In  some  cases,  if  the  refracting  media  are  not  too  much 
obscured  by  the  opacity,  it  may  be  possible,  during  the 
healing-stage,  to  make  out  minute  light  or  dark  blotches 
on  the  eyeground,  which  1  have  illustrated  in  my  Atlas 
of  Ophthalmoscopy,  vol.  vii.  of  this  series,  and  which  1  con- 
sider positive  signs  of  hereditary  lues.    The  larger  foci  of 


DISEASES  OF  THE  CORNEA.  147 

choroiditis  which  sometimes  appear  during  the  later  stages 
of  the  disease  have  no  significance. 

The  diagnosis  is  materially  simplified  by  the  fact  that 
parenchymatous  keratitis  never  undergoes  ulceration,  dif- 
fering in  this  respect  from  eczematous  inflammation  of 
the  cornea.  It  is  of  the  highest  importance  to  be  able  to 
distinguish  the  disease  from  glaucoma,  which  in  rare  in- 
stances occurs  in  childhood  ;  an  error  in  this  respect  might 
entail  fatal  consequences.  In  both  diseases  there  is  a 
faint  cloudiness  of  the  cornea  ;  but  in  keratitis  the  opac- 
ity is  irregularly  distributed  in  spots,  while  the  haze  of 
glaucoma  is  uniform  and  diffuse,  and  usually  less  marked 
than  in  keratitis.  Definite  information  can  be  obtained 
by  testing  the  tension,  if  necessary  under  anesthesia. 

Prognosis. — This  is  unfavorable  in  so  far  as  we  are 
unable  to  remove  the  inflammation  or  prevent  its  occur- 
rence in  the  other  eye.  The  prospect  of  vision  being 
eventually  restored  is,  however,  fairly  good,  recovery  is 
practically  perfect  in  many  cases,  and  almost  always  a 
serviceable  degree  of  visual  acuity  is  regained. 

Treatment. — This,  in  the  first  place  and  in  all  cases, 
must  include  a  tonic  regimen  ;  in  the  second  place,  pro- 
vided they  do  not  interfere  with  digestion,  the  milder 
iodids,  and  finally  the  careful  use  of  mercury  ;  the  latter 
drug,  however,  is  not  so  efficacious  as  in  the  inflamma- 
tions of  acquired  syphilis.  The  local  treatment  in  the 
early  stages  should  consist  of  atropin  and  dark  glasses 
to  relieve  the  irritative  symptoms.  Later  hot  fomenta- 
tions are  to  be  applied  ;  and  if  it  is  tolerated,  after  a  time 
yellow  oxid  of  mercury  salve  may  be  rubbed  into  the  eye. 
The  oxid  can  be  incorporated  with  ungt.  amylo-glycerin, 
0.1-0.2  in  10.0,  or  with  vasel in,  0.2-0.5  in  10.0,  applied 
with  a  glass  rod  and  well  rubbed  over  the  surface  of  the 
cornea  with  the  closed  lid,  once  a  day  or  every  other 
day.  It  may  not  be  borne  until  late  in  the  disease,  but 
its  continued  use  materially  hastens  the  clearing  of  the 
opacity.  [In  addition  to  the  tonic  regimen,  which  should 
include  cod-liver  oil,  arsenic,  iron,  etc.,  according  to  the 


148  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  20. 

Herpes  zoster  ophthalmicus,  taken  on  the  sixth  day  of  the  disease. 
The  patient,  a  healthy  man,  of  48  years,  at  that  time  complained  of  pain 
and  the  sensation  of  a  foreign  body  in  the  left  eye.  The  next  day  he 
had  a  slight  chill,  followed  by  nausea  and  lassitude,  so  that  he  went  to 
bed.  When  he  woke  up  the  following  morning  forehead  and  nose  were 
covered  with  an  eruption  which  caused  burning  pain.  The  left  eye  also 
became  violently  inflamed  and  he  could  not  see  well  with  it.  The  doc- 
tor ordered  lead-water  compresses  (a  mistake,  on  account  of  the  corneal 
affection),  whereupon  vision  became  worse.  At  the  time  of  admission 
the  vesicles  had  already  dried  up  aud  formed  crusts,  as  seen  in  the  pict- 
ure. The  lids  are  somewhat  edematous;  conjunctiva  very  red  and 
swollen,  and  covered  with  secretion  ;  the  entire  cornea,  with  the  excep- 
tion of  the  periphery,  is  denuded  of  epithelium,  and  where  any  exists 
it  is  grayish-white  and  opaque.  The  corneal  tissue  shows  diffuse  tur- 
bidity, aud  the  pupil,  which  is  moderately  dilated,  is  barely  visible. 
Sensibility  is  diminished  in  the  distribution  of  the  ophthalmic  branch 
of  the  fifth  nerve  and  entirely  lost  in  the  cornea  except  at  the  periphery. 
Under  a  bandage  the  corneal  epithelium  gradually  regenerated  in  two 
weeks  and  the  surface  cleared  somewhat.  When  the  patient  was  dis- 
missed, six  weeks  after  the  beginning  of  the  attack,  sensibility  had  not 
been  restored  in  the  cornea;  the  surface  was  uneven,  though  capable  of 
reflection,  but  the  tissues  were  obscured  by  macula*,  so  that  the  pupil 
was  barely  visible.  In  this  case  the  cornea  was  attacked  primarily,  at 
the  same  time  as  the  skin. 

indications,  suitable  diet,  regular  exercise,  massage,  etc., 
the  Editor  litis  much  faith  in  the  daily  inunction  of  mer- 
curial ointment,  which  may  be  kept  up  for  weeks  at  a 
time.] 

In  rare  instances  parenchymatous  keratitis  is  met  with 
in  a/squired  syphilis,  usually  in  association  with  iritis.  It 
is  somewhat  more  common  in  rheumatic  subjects,  forming 
in  such  cases  part  of  a  general  sderitis.  Portions  of  the 
cornea  near  the  scleritic  focus  become  opaque  and,  in  the 
course  of  time,  as  white  as  the  sclera  {sderotizmg  h  ra- 
titis);  the  cornea  loses  its  (areolar  outline  and  appears  to 
be  encroached  upon  by  the  sclera  (Plate  29,6).  [The 
disease  is  also  attributed  to  rachitis,  scrofula,  malaria,  and 
depressed  nutrition.     Rarely  it  may  begin  in  utero. — Ed.] 

Slight  injuries  may  give  rise  to  extensive  parenchyma- 


Tab.  20. 


t  r 


^ 


W 


•> 


m 


'st  /■:  Reichhold,  München. 


Diseases  of  the  cornea.  149 

tons  infiltration  of  the  cornea,  which  usually  disappears 
rapidly,  but  occasionally  persists  for  some  time  and  only 
partially  disappears.  It  is  therefore  important  to  observe 
the  greatest  care  in  the  treatment  of  slight  injuries,  either 
from  scratches  or  the  entrance  of  foreign  bodies  ;  often  it 
may  be  necessary  to  use  protecting  bandages.  Deep  dif- 
fuse infiltration  of  the  cornea  may  also  be  caused  by 
iridocyclitis. 


B.  CIRCUMSCRIBED  INFLAMMATIONS  OF  THE  CORNEA. 

These  forms  are  more  frequent  than  the  diffuse,  and 
the  most  frequent  of  them  is 

2.   Eczematous   Keratitis, 

also  called  phlyctenular  or  scrofulous  keratitis  [phlycten- 
ular keratoconjunctivitis.]  The  corneal  affection  may 
occur  independently  or  in  combination  with  eczema  of 
the  conjunctiva,  the  predisposing  causes  being  the  same 
for  both  forms. 

The  pustules  vary  quite  as  much  in  size  and  number 
in  the  independent  corneal  disease  as  in  conjunctival 
eczema;  but  here  also  each  individual  focus  has  a  dis- 
tinctly circular  contour.  The  smaller  vesicles,  which 
appear  as  minute  grayish  elevations  and  are  rapidly  con- 
verted into  small,  superficial  depressions  by  the  loss  of 
their  epithelial  covering,  heal  in  from  eight  to  ten  days, 
without  causing  congestion  or  leaving  any  appreciable 
permanent  opacity.  The  healing  of  laraer  ulcers  takes 
place  much  more  slowly  and  involves  a  greater  loss  of 
substance  ;  ulcers  with  purulent  floors  are  formed;  a  few 
thickened  blood-vessels  appear  at  the  edge  of  the  cornea 
and  gradually  work  their  way  toward  the  ulcer,  under- 
neath the  epithelium.  Unless  secondary  infection  takes 
place,  the  ulcer  clears  up  and  regenerates  under  its  fresh 
epithelial  covering,  as  may  be  seen  by  its  reflective  prop- 
erties and  failure  to  stain  with  fluorescin.  The  normal 
transparency  is  not  completely  restored,  but  a  permanent 


150  EXTEBNAL   DISEASES  OF  THE  EYE. 

Plate  2i. 

Foreign  Body  on  the  Cornea  and  Dermoid  Cyst  of  the  Orbit.— An  Italian 
marble-cutter,  18  years  old,  yesterday  received  a  splinter  in  his  Left  eye, 
which  appears  as  a  small  brown  particle  surrounded  by  a  yellow  infiltra- 
tion, a  little  to  the  temporal  side  of  the  center.  Patient  ictuses  to  have 
the  dermoid  cyst  removed.  The  swellingabove  the  left  lachrymal  sac  has 
existed  since  childhood,  and  has  increased  very  little  in  the  last  few 
years. 


morula  remains,  especially  after  a  centrally  situated  ulcer 
(Plate  23,6);  the  circular  shape  indicates  its  eczematous 
origin.  Large  pustules  may  penetrate  deeply  into  the 
corneal  tissue  and  eventually  cause  a  perforation,  usually 
after  the  development  of  iritis  and  turbidity  in  the 
anterior  chamber.  Large  single  ulcers  near  the  corneal 
margin  are  more  apt  to  perforate  than  central  ulcer-. 
Perforation  is  usually  followed  by  attachment  of  the  iris 
to  the  wound,  where  it  becomes  incarcerated  in  the  heal- 
ing  process  (Plate  23,  a). 

If  the  perforation  is  very  large  the  iris  is  apt  to  slip 
through  the  opening  (  i>rol<i[>s<  of  the  iris),  and  if  there 
i-  extensive  purulent  infiltration  from  secondary  infection, 
the  corneal  tissues  may  break  down  and  a  staphyloma 
result.  This  is  formed  as  follows  :  The  iris  which  closes 
the  perforation,  although  reinforced  by  granulation-  and 
scar-tissue,  is  unable  to  withstand  the  intraocular  pressure, 
which  is  usually  increased  by  secondary  glaucoma,  and 
gradually  bulges  forward.  In  a  few  weeks  or  months  the 
staphyloma  is  completed — a  hemispherical,  grayish-white 
or  bluish  protrusion,  which  causes  a  marked  deformity. 
Vision  is  usually  destroyed  much  earlier. 

If  the  disease  is  protracted  and  the  eruptions  constantly 
recur,  accompanied  by  vascularization,  so-called  eczematous 
or  scrofulous  pannus  (Plate  22)  results.  Numerous  super- 
ficial blood-vessels  unite  with  new  and  old  foci  and  their 
maculae  to  form  a  grayish-red  coating  over  the  face  of  the 
cornea  and,  of  course,  interfere  greatly  with  vision.  If 
the  condition  persists  for  any  length  of  time  an  extensive 


^M 


DISEASES  OF  THE  CORNEA.  151 

opacity  may  result  and  cause  permanent  diminution  of 
visual  acuity. 

Corneal  eczema  very  often  occurs  secondarily  to  eczema 
of  the  conjunctiva.  Pustules  appear  directly  on  the  cor- 
neoscleral junction,  partly  on  the  cornea  and  partly  on 
the  conjunctiva.  The  adjacent  corneal  area  becomes 
cloudy,  and  a  few  blood-vessels  make  their  appearance. 
This  is  the  so-called  marginal  keratitis.  If  the  marginal 
phlyctenule  are  large  (1.5-2  mm.)  the  corneal  half  is  often 
converted  into  a  deep  (excavated)  ulcer,  with  strong  ten- 
dency to  perforation  (Plate  23,  a)  ;  or  the  phlyctenular 
ulcer  may  leave  the  periphery  and  creep  toward  the  cen- 
ter of  the  cornea,  forming  the  so-called  migratory  pustule 
or  fascicular  keratitis.  The  mechanism  of  this  process  is 
not  well  understood.  Most  cases  do  not  come  under  ob- 
servation until  after  the  process  is  completed,  weeks  or 
months  after  the  beginning  of  the  inflammation,  when  the 
following  picture  is  seen  :  A  bundle  of  minute  blood- 
vessels, from  1  to  2  mm.  broad,  extends  from  some  portion 
of  the  periphery  toward  the  center  of  the  cornea,  running 
beneath  the  surface  in  a  straight  or  slightly  curved  line 
and  terminating  in  a  crescentic,  grayish  elevation.  When 
the  process  is  kept  under  observation  for  some  time  the 
blood-vessels  appear  to  push  before  them  the  crescentic  in- 
filtration in  which  they  end;  the  latter  gradually  wanders 
toward  the  center  or  across  the  face  of  the  cornea,  between 
the  center  and  the  periphery,  its  convex  border  presenting 
toward  the  center.  The  process  is  attended  with  severe 
irritation  and  blepharospasm ;  children  evince  a  con- 
stant desire  to  bury  their  heads  in  pillows  or  creep 
into  dark  corners.  Whenever  the  disease  is  seen  at  its 
inception,  the  original  cause  is  always  found  to  be  a  mar- 
ginal pustule.  Occasionally  several  fascicule  are  seen  in 
the  same  cornea,  or  one  in  each  eye.  The  entire  course 
of  the  fascicular  keratitis  across  the  cornea  is  marked  by  a 
stripe-like  opacity,  which  remains  for  years  as  evidence  of 
the  disease,  and  usually  produces  permanent  diminution 
of  vision,  as  it  preferably  affects  the  pupillary  region. 


152  EXTERNAL   DISEASES  OF  THE  EYE. 

Plate  22. 

Eczema  of  the  Cornea  and  Conjunctiva  on  Both  Sides,  with  Eczema 
of  the  Hairy  Scalp,  Nose,  and  Mouth.— The  patient,  a  delicate,  under- 
sized boy  of  U  years,  very  pale,  has  suffered  from  inflamed  eyes  for  the 
past  two  years.  There  is  conjunctivitis  of  both  eyes,  with  copious  secre- 
tion and  eczematous  pannus  over  both  cornea-,  which  are  covered  with 
infiltrates  of  various  sizes,  fresh  pustules,  and  macules  of  long  standing. 
A  recent  pustule  is  to  be  seen  in  the  nasal  half  of  the  cornea  in  the  left 
eye:  in  the  right  eye  a  crescentic  opacity  in  the  lower  segment  betrays 
the  former  occurrence  of  fascicular  keratitis.  The  cutaneous  eczema 
proves  the  common  origin  of  the  various  manifestations. 

Marginal  phlyctenule  sometimes  lead  to  the  develop- 
ment of  eczematous,  marginal  pannus,  or,  which  is  worse, 
to  a  long  marginal  ulcer,  by  the  coalescence  of  several 
adjacent  pustules.  The  adjacent  portions  of  the  cornea 
become  the  seat  of  extensive  infiltration,  and  perforation 
is  very  apt  to  result. 

While  in  the  conjunctiva  the  process  is  attended  with 
only  a  moderate  degree  of  irritation,  eczema  of  the  cornea 
gives  rise  to  marked  subjective  symptoms,  pain,  a  feel- 
ing of  grittiness,  as  if  the  eye  contained  a  foreign  body, 
difficulty  in  opening  the  lids,  or  even  blepharospasm,  and 
excessive  lachrymation.  Vision  is  affected  as  soon  as  the 
process  invades  the  pupillary  region. 

Diagnosis. — The  circular  shape  of  the  individual  pust- 
ules and  the  presence  of  eczema  in  other  parts  of  the 
body  are  the  chief  diagnostic  points  (Plate  22).  In  addi- 
tion much  information  may  be  gained  by  observing  the 
ciliary  congestion  and  the  reflecting  properties  of  the  cor- 
neal surface.  If  many  old  and  recent  opacities  are  pres- 
ent, associated  with  pronounced  vascularization,  the  picture 
of  parenchymatous  keratitis  may  be  simulated.  The  latter 
condition,  however,  is  never  productive  of  tissue-destruc- 
tion, and  the  circular  opacities  which  sometimes  develop 
in  the  later  stages  are  less  sharply  defined  than  are  the 
macula?  of  eczema,  which,  in  addition,  are  characterized 
by  a  constant  central  depression. 

The  prognosis  is  influenced  by  the  unfortunate  ten- 


Tab.  22. 


I 


\ 


I 


LUh.  Anst  F. ' Reichtwld ,  München. 


DISEASES  OF  THE  CORNEA,  153 

dency  to  relapses,  which  threaten  to  protract  the  disease 
indefinitely.  If  a  large  pustule  develops  in  the  center  of 
the  pupil,  permanent  impairment  of  vision  is  the  unavoid- 
able result.  In  strumous  subjects  external  conditions, 
such  as  food,  living-quarters,  cleanliness,  etc.,  have  a 
marked  effect  on  the  outcome  of  the  disease. 

Treatment. — General  measures  to  neutralize  the  evil 
effects  of  the  strumous  habit  are  the  first  requisite.  If 
the  patient's  surroundings  as  to  food,  lodging,  and  clean- 
liness are  unsatisfactory,  every  effort  should  be  made  to 
get  him  into  a  hospital,  where  his  diet  can  be  carefully 
regulated.  Iron  (ferr.  sacch.  solub.  [the  Editor  prefers 
the  iodids  of  iron,  to  which  Fowler's  solution  may  be 
added])  has  a  stimulating  effect  on  the  appetite,  especially 
for  meats,  and  acts  as  a  general  tonic.  This  should  be 
supplemented  by  saline  baths,  and  during  the  winter  with 
cod-liver  oil ;  in  obstinate  cases  good  results  are  some- 
times obtained  by  a  course  of  sweating. 

Locally,  atropin  in  sufficient  quantities  (3-8  drops  of  a 
sterile  1  per  cent,  solution  or  several  applications  of 
atropin-vaselin)  to  check  the  pain  is  indicated.  A  com- 
press-bandage, which  in  itself  tends  to  allay  the  pain,  is 
then  applied  to  guard  against  secondary  infection  and 
purulent  infiltration  of  the  abrasions,  which  are  very  apt  to 
occur  in  eczema.  The  best  form  of  bandage  consists  of 
one  wound  over  a  pad  of  cotton,  which  is  kept  moist  with 
a  1  :  5000  solution  of  mercuric  chlorid,  more  particu- 
larly if  there  is  catarrh.  The  dressing  must  not  be  re- 
moved until  every  single  abrasion  is  sufficiently  covered 
with  epithelium.  To  check  the  catarrhal  secretion,  which 
does  not  contraindicate  the  bandage,  the  tarsal  conjunctiva 
should  be  painted  once  every  day  with  a  1  to  2  per  cent, 
solution  of  silver  nitrate. 

If  purulent  infiltration  has  set  in  around  the  pustules, 
near  the  corneal  margin,  for  instance,  the  bandage  should 
be  tightly  drawn.  This  is  the  only  condition  in  which 
pressure  is  desirable  in  the  application  of  the  dressings. 

Before  the  caustic  treatment  of  fascicular  keratitis  was 


154  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  23. 

a.  Perforation  of  the  Cornea  by  an  Eczematous  Ulcer,  with  Adhesion 
of  the  Iris. — Patient  is  a  scrofulous  boy,  10  years  old,  who  had  been 
treated  outside  of  the  hospital  for  the  past  four  weeks,  and  was  admitted 
at  the  time  of  this  recent  perforation.  It  is  evident  from  the  shape  of 
the  perforation  that  it  is  due  to  an  eczema-pustule,  even  without  the 
evidence  of  eczema  in  the  other  eye.  There  is  typical  ciliary  congestion. 
The  pupil,  owing  to  the  adhesion  of  the  iris,  is  displaced  toward  the 
temporal  side.  A  compressing  bandage  was  applied  for  two  weeks,  and 
the  perforation  healed,  leaving  a  smooth,  slightly  pigmented  scar.  The 
pupillary  distortion  is  permanent.  After  a  few  weeks  vision  was  practi- 
cally restored. 

h.  Macula  of  the  cornea  of  long  standing,  the  remains  of  an  eczema- 
tous ulcer.  The  circular  outline  of  the  scar  and  the  loss  of  cilia  indicate 
that  eczema  is  the  causal  agent.  The  eye  at  the  present  time  is  free 
from  irritation. 

introduced,  the  malady  was  most  distressing  to  the  patient 
and  a  great  trial  to  the  physician.  Xow  we  resort  to 
cauterization,  usually  with  the  mitigated  stick,  well  drawn 
out  to  a  point,  under  local  anesthesia  with  Cocain.  It  is 
important  to  have  the  patient  under  good  control,  so  as  to 
avoid  injuring  the  healthy  tissues,  hence  the  services  of  a 
capable  assistant  are  indispensable.  If  the  first  applica- 
tion fails  to  arrest  the  process  a  second  should  be  tried. 
The  destruction  of  the  advancing  crescent  is  speedily  fol- 
lowed by  cure,  as  the  rich  vascularity  of  the  tissues  is  most 
favorable  to  regeneration. 

It  is  most  important  in  all  forms  of  eczematous  kerat- 
itis to  apply  a  stimulating  remedy  at  the  most  favorable 
moment  for  hastening  the  reparative  process.  For  this 
purpose  a  1  to  2  per  cent,  salve  of  yellow  oxid  of  mercury 
(well  mixed  and  comminuted)  usually  suffices.  Its  use  is 
indicated  as  soon  as  the  inflammation  lias  begun  to  sub- 
side, when  the  ulcers  are  usually  clean  and  vessel-forma- 
tion has  begun.  The  salve  fulfils  the  double  purpose  of 
clearing  up  the  opacities  and  preventing  relapse-,  and  its 
application  must  be  persevered  in  for  some  time. 

[The  treatment  of  the  rhinopharynx  i<  essential  in  all 
these  cases,  and  always  there  will  be  found  rhinitis,  hyper- 


Tab.  23. 


a 


i 


& 


h 


LithAnst  E Reichhold,  München . 


DISEASES  OF  THE  CORNEA.  155 

trophied  turbinate,  adenoid  vegetations,  etc.  The  lachry- 
monasal  duet  should  be  kept  patulous.  Severe  corneal 
ulcers  arc  managed  on  general  principles. — Ed.] 

3.  Herpes  Corneae. 

Herpes  is  another  form  of  keratitis  of  a  dermoid  char- 
acter and  occurs  as  herpes  zoster  or  as  herpes  febrilis. 

Herpes  poster  (see  p.  92)  produces  various  lesions  in 
the  cornea  : 

1.  The  vesicular  eruption  may  appear  primarily  in  the 
cornea  at  the  same  time  as  on  the  skin  (Plate  20).  The 
vesicles  appear  in  groups,  rapidly  break  down,  and  form 
an  irregular,  shallow  ulcer,  which  sometimes  becomes 
deeper  and  gives  rise  to  extensive  purulent  infiltration 
of  the  cornea.  In  the  mildest  cases  the  site  of  the  vesic- 
ular eruption  is  marked  by  a  more  or  less  permanent 
opacity  (Plate  20).  Iritis  occurs  in  some  instances  as  a 
complication.  The  most  conspicuous  symptom  in  this 
and  in  the  following  forms  of  herpes  zoster  is  lessen- 
ing or  abolition  of  the  sensibility,  which  is  determined 
by  touching  the  eye  with  a  twist  of  cotton. 

2.  In  some  cases  anesthesia  occurs  in  circumscribed 
areas,  and  upon  careful  examination  delicate  nebula?,  often 
composed  of  numerous,  small  round  dots,  are  seen  in  these 
areas  and  sometimes  produce  shallow  ulcers,  but  in  most 
cases  persist  for  some  time  without  breaking  down  and 
eventually  disappear  entirely.  These  opaque  spots  appear 
to  be  directly  dependent  upon  the  anesthesia  or  disease  of 
the  trifacial,  which  is  the  original  cause  of  herpes. 

3.  Paralysis  of  the  trifacial  may  give  rise  to  neuro- 
paralytic keratitis,  a  dangerous  form  of  inflammation 
caused  by  pyogenic  micrococci,  which  may  lead  to  exten- 
sive ulceration  or  purulent  (colliquative)  necrosis  of  the 
corneal  tissues. 

The  treatment  of  herpes  zoster  consists  in  the  careful 
and  continued  application  of  a  protective  (sealed)  band- 
age, which,  if  persevered  in,  may  possibly  ward  off  neuro- 
paralytic keratitis.    For  this  reason  it  should  be  employed 


156  EXTERNAL   DISEASES  OF  THE  EYE. 

Plate  24. 

Herpes  Corneae  Febrilis.— These  eighteen  outline  drawings  show 
various  shapes  and  positions  of  herpes-ulcers,  taken  from  thirteen  cases 
under  my  observation  during  the  epidemic  of  influenza  in  1890-91. 
(They  are  also  to  be  found  in  the  work  of  Dr.  Hagnauer.  who  was  at 
that  time  my  assistant.1)  In  Figs.  1.  5,  6,  7,  13,  and  17  we  see  macules 
from  former  attacks  of  herpes,  recognized  by  their  irregular  outline,  re- 
sembling a  geographical  map.  Figs.  10  and  15  show  the  macules  which 
resulted  from  the  ulcers  seen  in  7  and  in  9  and  12.  Figs.  12  and  14 
illustrate  the  coalescence  of  a  discrete  eruption,  and  Fig.  17  a  magnified 
picture  of  the  original  ulcer.  In  Figs.  11  and  12  slight  vascularization  is 
beginning  to  show  itself. 


even  when  anesthesia  is  the  only  symptom,  and  is  impera- 
tively demanded  when  there  is  destruction  of  the  corneal 
tissue. 

Herpes  corneae  febrilis  (Horner)  should  engage  our 
interest  if  only  because  it  proves  conclusively  that  proc- 
esses can  occur  in  the  cornea  in  every  respect  analogous 
to  cutaneous  diseases,  and  that  the  individual  foci  possess 
the  same  shape,  on  a  very  much  reduced  scale,  as  in  the 
skin. 

It  is  important  to  note  that  the  vesicles  on  the  cornea 
are  much  more  delicate  in  structure,  and  therefore  break 
down  and  disappear  more  rapidly  than  on  the  skin  ;  hence 
the  diagnosis  is  usually  made  from  the  characteristic 
shape  of  the  subsequent  loss  of  substance,  the  herpetic 
ulcer  and  its  peculiarities.  After  the  vesicles  burst  (in 
from  one  to  two  days)  the  cornea  for  the  next  week  or  two 
looks  as  if  it  had  been  scratched  with  a  sharp  splinter. 
The  irritation  is  moderate,  and  the  injured  spot  as  well  as  its 
immediate  surroundings,  only  slightly  opaque.  In  a  week, 
or  from  one  to  two  weeks  after  the  first  appearance  of  the 
eruption,  the  last  shreds  of  the  vesicle-walls  separate  and 
the  ulcers  present  their  typical  sinuous  outline  and  clear- 
cut  edges.  The  contour  can  be  very  clearly  brought  out 
by  staining   with  fluoresdn,  a  procedure  of  the  greatest 

1  Die  Misdeutungen  des  Herpes  Cornex  Febrilis,  Inaug.  Dissert.  Zürich, 
1891. 


Tab.  24. 


/j 


// 


/ 


11 


f4 


fö 


^V^ 


f? 


LüfuAnsl  t: Reichhol il ,  München. 


& 


DISEASES  OF  TUE  CORNEA.  157 

diagnostic  value  in  doubtful  cases.  [As  pointed  out  by 
Veasey,  toluidin-blue  will  also  stain  the  cornea  when  it  is 
deprived  of  epithelium. — Ed.]  Before  the  stain  is  intro- 
duced, a  few  drops  of  a  2  per  cent,  solution  of  Cocain  arc 
instilled  into  the  eye,  which  has  the  incidental  advantage 
of  intensifying  the  color.  One  drop  of  an  alkaline  solu- 
tion of  fluorescin  (fluorescin,  0.2  ;  sod.  carb.,  0.3  ;  aqua 
destill.,  10.0)  is  then  applied  to  the  cornea  and  the  eye 
kept  closed  for  half  a  minute,  after  which  it  is  thoroughly 
washed  with  a  1  :  5000  bichlorid  solution.  The  peculiar 
shape  of  the  ulcer  at  once  becomes  manifest  (Plates  24  and 
25,  a).  Occasionally  more  than  one  ulcer  is  to  be  seen. 
As  a  rule,  the  original  outline  is  retained  throughout  the 
course  of  the  disease  ;  in  exceptional  cases,  however,  small 
extensions  make  their  appearance  after  a  few  days,  due  to 
deeper-lying  ulcers  whose  epithelial  covering  has  just 
separated.  Of  course,  if  secondary  infection  and  infiltra- 
tion of  the  surrounding  tissue  supervene,  the  ulcer  may 
assume  any  size,  and  may  e.ven  result  in  a  true  hypopyon. 
The  distinguishing  feature  of  herpetic  ulcer  is  the  exceed- 
ingly slow  healing  process,  requiring  from  four  to  eight 
weeks  for  its  completion,  which  is  probably  due  to  the 
scant  and  sluggish  vessel- formation. 

The  explanation  may  be  found  in  the  fact  that  the 
nerves  are  diseased  in  herpes  febrilis  as  well  as  in  herpes 
zoster;  this  is  shown  by  the  diminished  sensibility  of  the 
cornea  observed  in  many  cases.  As  in  all  forms  of  corneal 
ulcer,  regeneration  begins  at  the  edges ;  a  new  epithelial 
covering  overspreads  the  floor  of  the  ulcer,  so  that  it  recov- 
ers its  reflecting  power  and  does  not  stain  with  fluorescin. 
The  original  level  is  very  gradually  restored,  although  a 
more  or  less  pronounced  macula  always  remains  and  for 
years  afterward  retains  the  shape  of  the  original  ulcer 
(Plate  24). 

Herpes  cornea?  does  not  appear  in  successive  crops,  like 
eczema  ;  but  it  is  prone  to  recur  in  the  same  eye,  or,  by 
way  of  variety,  in  the  other  eye,  whenever  the  individual 
happens  to  have  fever.    An  ordinary  cold  or  a  short  attack 


158  EXTERNAL   DISEASES  OF   THE  EVE. 

Plate  25. 

a.  Herpes  corneae  febrilis,  three  weeks  after  the  beginning  of  the  dis- 
ease, stained  with  fluorescin,  showing  a  green  ulcer,  oi  irregular,  sinuous 
shape,  in  the  temporal  half  of  the  cornea.  (The  green  color  isa  little  too 
light  in  the  figure.)  A  slight  degree  of  vessel-formation  may  be  seen  at 
tin' temporal  margin  of  the  cornea.  The  conjunctiva  is  stained  yellow 
by  the  fluorescin  and,  in  addition,  shows  marked  ciliary  congestion. 
The  pupil  is  dilated  with  atropin. 

h.  Hypopyon-keratitis.— Just  below  the  center  of  the  cornea  is  a  puru- 
lent infiltration  which  developed  in  the  course  of  a  few  days.  The  limit 
of  the  infiltration  remains  stationary.  The  hypopyon  in  the  anterior 
chamber  is  2  mm.  high.  No  history  of  traumatism.  There  are  moderate 
dacryostenosis  and  chronic  conjunctival  catarrh.  Satisfactory  cure  after 
several  applications  of  pure  carbolic  acid.     Visual  acuity  |. 


of  gastric  fever  suffices  to  bring  it  out.  The  malady  is 
particularly  common  after  influenza.  In  spite  of  the  long 
duration  of  the  process,  the  iris  rarely  becomes  involved, 
unless  a  secondary  infection   takes  place. 

The  diagnosis  is  readily  made  from  the  symptoms  de- 
scribed, and  especially  from  the  color  obtained  with  fluo- 
rescin. Sometimes  a  herpetic  ulcer  fails  to  show  the 
typical  sinuous  contour  (resembling  a  geographical  map), 
in  which  case  we  base  our  diagnosis  on  the  slow  process  of 
repair.  At  first  the  diseased  spots  may  easily  be  mistaken 
for  scratches,  except  for  the  absence  of  a  history  of  trau- 
matism. It  is  often  difficult  to  determine  the  febrile 
nature  of  the  disease,  because  the  patients  usually  present 
themselves  long  after  they  have  forgotten  any  feverish 
symptoms  they  may  have  had.  Occasionally  a  herpetic 
macula  from  a  former  attack  is  detected  and  helps  to  clear 
up  the  diagnosis. 

Prognosis. — We  should  emphasize  the  probability  of 
a  long  duration,  and,  if  the  lesion  is  centrally  situated, 
the  unavoidable  permanent  impairment  of  vision.  On 
•the  other  hand,  if  the  ulcer  is  properly  treated  there  is 
little  danger  of  its  spreading.  Relapses  are  not  infre- 
quent, and  little  or  nothing  can  be  done  to  prevent  their 
occurrence. 


Tab.  25. 


\ 


\m 


t> 


Lüh.Anst  f.  Reiclüwlil.  Manchen. 


DISEASES  OF  THE  CORNEA.  159 

The  treatment  is  the  same  as  for  corneal  ulcer ;  it 
consists  in  atropin  and  the  constant  use  of  a  bandage,  to 
be  worn  until  the  reflex  is  restored  in  every  part  of  the 
ulcer  (for  its  chief  object  is  to  guard  the  ulcer  against  con- 
tamination of  any  kind,  especially  of  an  infectious  nature). 
The  bandage  also  serves  to  diminish  the  pain  by  keeping 
the  lids  quiet,  and  allows  the  process  of  tissue-repair  to  go 
on  undisturbed.  When  at  last  a  firm  epithelial  covering 
has  been  formed,  the  bandage  may  be  dispensed  with,  and 
yellow  oxid  of  mercury  salve  (sec  p.  147)  may  then  be 
used  for  from  three  to  four  weeks,  to  complete  the  cure. 
In  the  beginning  of  the  disease  one  or  two  applications  of 
sublimate  solution  with  a  cotton  pledget  (under  cocain 
anesthesia)  are  of  advantage. 

4.  Hypopyon=keratitis,   or  Purulent  Ulcer  of  the  Cornea. 

The  slightest  abrasion  on  the  corneal  surface  may  open 
a  way  for  the  entrance  of  pyogenic  microorganisms,  pro- 
viding some  infectious  material  containing  them  is  present 
and  the  cornea  at  the  time  affords  a  favorable  culture- 
medium.  The  second  condition  is  satisfied  in  individuals 
weakened  by  disease,  bad  food,  or  senile  decay.  The 
diseases  which  produce  such  a  condition  are  measles,  scar- 
let fever,  typhoid  fever,  whooping-cough,  variola,  etc. 
Infectious  material  is  especially  abundant  in  catarrh  of 
the  lachrymal  sac  or  of  the  conjunctiva.  Farmers  often 
suffer  from  purulent  keratitis,  probably  because  their 
hands  are  soiled  with  earth,  although  the  unhygienic  con- 
ditions under  which  they  live  are  no  doubt  partly  respon- 
sible. I  have  often  found  a  perceptible  reduction  of  the 
hemoglobin  in  patients  of  this  class.  Then,  too,  the  heat 
which  prevails  at  harvest-time  probably  favors  the  occur- 
rence of  infection. 

The  lesions  are  usually  of  a  traumatic  nature,  sometimes 
only  slight  abrasions  made  by  a  straw,  a  finger-nail,  or  a 
twig,  which  create  entering  points  for  infection.  These 
may  be   established  by  foreign    bodies.     Sometimes  the 


160  EXTERNAL    DISEASES  OF   THE  EYE. 

Plate  26. 

".  Serpiginous  Ulcer  of  the  Cornea  ;  Pterygium.  —Laborer,  65  years  old. 
Five  days  ago,  while  patient  was  chopping  wood,  a  twig  struck  him  in 

the  left  eye.  He  now  presents  a  large  growing  ulcer,  witli  suppurating 
edges,  while  tin-  center  is  already  in  process  of  regeneration.  He  says  he 
has  been  troubled  with  excessive  lachrymation  in  both  eyes  for  six  <>r 
seven  years.  The  lachrymal  canaliciili  are  occluded.  A  fairly  huge 
pterygium  has  been  present  for  some  time.  Below  the  cornea  the  ocular 
conjunctiva  shows  a  moderate  degree  of  edema.  An  hypopyon,  1  mm. 
in  depth,  increased  during  the  next  few  days  in  spite  of  repeated  eleans- 
ing  of  the  ulcer  with  pure  carbolic  acid,  and  finally  tilled  two-thirds 
of  the  anterior  chamber,  so  that  it  was  decided  to  evacuate  the  jms  by 
puncture.  The  ulcer  eventually  healed  completely.  A  large  central 
leukoma  remained.      Visual  acuity:   movements  of  the  hand. 

h.  Serpiginous  ulcer  of  the  cornea,  in  an  advanced  stage.  The  pa- 
tient is  a  farmer.  To  years  »Id.  He  has  felt  stabbing-  and  hurning-paius 
in  the  eye  for  two  weeks;  nis  friends  noticed  a  spot  and  inflammation. 
Three  days  ago  he  consulted  a  doctor,  who  sent  him  to  the  clinic 
Marked  senile  symptoms:  hemoglobin,  80  per  cent.  The  eye  lias 
watered  for  some  time  ;  canaliculi  are  impervious.  The  eye  is  very  red  ; 
in  the  upper  nasal  portion  of  the  cornea  is  a  large  ulcer  with  broad,  green- 
ish-yellow edges  and  attenuated,  bulging  center,  through  which  the 
dark  anterior  chamber  is  dimly  seen.  Hypopyon  2*  mm.  deep;  the 
aqueous  humor  is  turbid.  The  use  of  the  thermocautery  i>  followed 
by  perforation  of  the  ulcer  and  evacuation  of  the  hypopyon.  Two  days 
later  the  edges  again  suppurate,  espeeially  about  the  lower  portion  of  the 
ulcer.  Cauterization  with  carbolic  acid.  On  the  next  day  the  ulcer  had 
progressed,  especially  below.  At  this  time  the  picture  was  taken. 
Another  application  of  the  galvanocautery  arrest^l  the  process.  In  five 
days  the  ulcer  cleared  up.  Cure  after  one  month,  with  the  formation  of 
a  smooth  scar,  hut  no  staphyloma.     V  =  ^fo. 


offending  object  is  the  direct  cause  of  the  infection,  if  it 
happens  to  be  contaminated. 

Aseptic  wounds  of  the  cornea,  even  if  quite  lame  heal 
rapidly  and  take  on  a  new  covering  of  epithelium  in 
a  very  short  time;  hut  if  they  become  infected,  they 
first  turn  gray  and  then  yellow,  and  the  discoloration 
spreads  to  the  immediate  surroundings;  an  infiltration 
develops  by  the  migration  of  leukocytes  toward  the 
injured  spot,  where  they  accumulate  in  the  corneal  sub- 
stance in  ever-increasing  numbers.     The  purulent  nature 


Tab.-  26. 


*** 


■ 


l.itli . . Inst  +'■  Heichhohi.  München . 


DISEASES  OF  THE  CORNEA.  161 

of  the  infiltration  betrays  itself  in  the  yellow  discolora- 
tion. Now,  the  same  process  may  take  place  if  a  simple 
ulcer — caused  by  eczema  or  herpes,  for  instance — becomes 
infected.  In  proportion  as  the  inflammation  and  the  «•on- 
sequent  accumulation  of  leukocytes  increase,  the  rest  of 
the  cornea  becomes  covered  with  a  delicate,  diffuse  cloudi- 
ness and  its  reflex  is  lost.  As  soon  as  the  purulent  focus 
attains  a  certain  size,  iritis  supervenes ;  the  aqueous 
humor  becomes  turbid,  synechia?  are  formed  around  the 
pupillary  margin,  and  pus  collects  in  the  anterior  chamber, 
at  first  a  mere  yellow  line  along  the  lower  margin  of  the 
chamber,  later  increasing  to  a  segment  (Plates  25,  A,  and 
26,  a),  which  may  occupy  one-half  or  three-fourths  of  the 
anterior  chamber. 

This  purulent  iritis  is  caused  by  a  toxin,  elaborated 
by  the  microorganisms  in  the  cornea,  finding  its  way  into 
the  anterior  chamber  (just  as  atropin  does,  for  instance) 
and  setting  up  an  inflammatory  process.  The  pathogenic 
bacteria  themselves  are  not  likely  to  penetrate  so  far,  un- 
less there  has  been  a  very  deep-reaching  infiltration  and 
perforation  into  the  anterior  chamber ;  hence  a  hypopyon 
is  usually  free  from  bacteria. 

As  the  purulent  inflammation  increases,  inflammatory 
edema  develops  in  the  bulbar  conjunctiva  and  eventually 
in  the  lids.  The  edema  becomes  very  marked  and  in- 
volves the  orbital  contents  (giving  rise  to  protrusion)  ;  if 
extensive  destruction  of  the  corneal  substance  takes  place, 
the  suppurative  process,  penetrating  into  the  iris  and 
deeper  coats  of  the  eve,  gives  rise  to  panophthalmitis 
(Plate  27). 

It  must  be  remembered  that  a  purulent  infiltration  of 
the  cornea  is  very  likely  to  result  in  general  sloughing  ; 
the  primary  focus?  which  is  usually  circular  in  shape, 
breaks  down  in  the  center  and  an  ulcer  is  formed,  the 
floor  and  margins  of  which  exhibit  a  grayish-yellow  dis- 
coloration. The  patient  usually  complains  of  pain  in  the 
eye,  headache,  and  dimness  of  vision,  if  the  ulcer  is  situ- 
ated within  the  pupillary  region,  There  are,  however, 
li 


162  EXTERNAL  DISEASES  OF  THE  EVE. 

Plate  27. 

Suppuration  of  the  Cornea  from  Serpiginous  Ulcer  ;  Panophthalmitis. 
— The  patient,  who  is  73  years  old  and  a  farmer  by  occupation,  was 
treated  in  this  clinic  a  year  ago  for  conjunctival  catarrh,  which  is  now 
present,  as  may  he  seen  hy  the  dried  secretion  at  the  inner  canthus  of 
the  left  eye.  The  tear-duct  is  patulous  on  both  sides.  Four  days  ago 
the  patient  noticed  a  burning  sensation  in  the  right  eye,  but  paid  no  at- 
tention to  it  until  yesterday,  when  he  found  that  he  could  not  see  clearly. 
He  does  not  know  of  any  injury.  In  the  right  eye  the  lids  are  glued 
fast  with  secretion,  the  conjunctiva  is  red  and  swollen,  and  there  is 
ciliary  congestion  ;  the  cornea  is  clear  except  at  the  center,  which  is  oc- 
cupied by  a  circular,  shallow  ulcer,  2  mm.  in  diameter,  not  serpiginous, 
but  of  a  uniform  greenish  or  yellow  color.  Small  hypopyon.  Behind 
and  a  little  below  the  ulcer  in  the  anterior  chamber  a  strip  of  purulent 
exudate  is  adherent  to  the  cornea.  Aqueous  humor  turbid.  The  ulcer 
was  immediately  incised  after  the  method  of  Saemisch.  The  exudate 
behind  the  ulcer  was  extracted,  and  brought  with  it  a  membrane  which 
lined  almost  the  entire  anterior  chamber.  The  next  day  the  sloughing 
of  the  cornea  had  increased,  and  the  incision  was  opened  once  more. 
On  the  following  day  the  purulent  ulcer  was  much  larger,  a  large  amount 
of  pus  had  collected  in  the  anterior  chamber,  and  there  was  incipient 
panophthalmitis,  with  edema  of  the  lids  and  copious  purulent  discharge 
from  the  conjunctiva  see  Plate).  On  the  fifth  day  after  treatment  was 
begun  the  entire  cornea  was  converted  into  a  greenish-yellow  purulent 
infiltrate,  and  in  the  course  of  the  next  few  days  sloughed  away  more 
and  more,  while  panophthalmia  increased  pari  passu. 


so-called  torpid  ulcers  of  this  kind,  which  give  little  pain 
(perhaps  because  the  sensitive  fibers  are  paralyzed  by  the 
toxin),  but  are  none  the  less  serious. 

The  most  frequent,  as  well  as  the  most  dangerous,  type 
of  hypopyon-keratitis  is  the  serpiginous  ulcer,  one  of  the 
most  malignant  forms  of  corneal  disease,  which  is  attended 
with  great  danger  to  the  eyesight  from  the  fact  that  it 
preferably  affects  the  central  portions  of  the  cornea.  The 
ulcer  spreads  rapidly  by  one  or  more  of  its  margins  ad- 
vancing in  the  form  of  an  elevated  curve  of  yellow  infil- 
tration (see  Plate  26),  while  the  parts  of  the  nicer  lying 
behind  this  propagating  are.  as  it  is  called,  show  more  or 
less  tendency  to  repair.  Hypopyon  soon  develop-.  Left 
to  itself,  the  lesion  at  first  produces  extensive  destruction 


DISEASES  OF  THE  CORNEA.  163 

of  the  superficial  tissues,  and  later  penetrates  more  deeply, 
so  that  perforation  often  occurs,  followed  by  prolapse  of 
the  iris  and,  finally,  panophthalmitis. 

It  appears  from  the  investigations  of  Uhthoff,  Axen- 
feld,  and  others  that  the  serpiginous  ulcer  is  almost 
always  caused  by  the  Frärikel-  Weichselbaum  pneumococcusy 
while  the  other  purulent  ulcers  of  the  cornea  are  due  to 
the  action  of  staphylococci  and  streptococci  (much  less  fre- 
quently to  aspergillus),  and  only  in  rare  instances  to  pneu- 
mococci. 

Among  these  other  forms  of  hypopyon-keratitis  we  in- 
clude the  purulent  ulcerations  which  occur  in  the  course 
of  gonorrheal  and  diphtheritic  conjunctivitis,  and  in  ma- 
rasmic  infants  who  are  afflicted  with,  and  eventually  die 
of,  grave  digestive  disturbances ;  also  keratitis  neuropara- 
lytica,  caused  by  paralysis  of  the  trifacial  nerve.  These 
forms  of  purulent  keratitis  are  capable  of  causing  quite 
as  extensive  destruction  in  the  eye  as  the  serpiginous 
ulcer. 

The  invariable  termination  of  all  purulent  ulcers,  be 
they  large  or  small,  is  a  dense,  cloudy  scar  or  leukoma, 
which  usually  produces  a  permanent  visual  disturbance, 
as  it  is  situated  wholly  or  partly  within  the  pupillary  re- 
gion. If  the  perforation  is  small,  the  result  is  a  mere 
adhesion  of  the  iris  (adherent  leukoma) ;  on  the  other  hand, 
the  scar  of  a  large  perforation  may  become  distended  and 
even  give  rise  to  a  partial  or  total  corneal  staphyloma. 
Small  ulcers  sometimes  leave  a  membrane  of  inflammatory 
exudate  in  the  pupil,  which  interferes  with  vision.  If  ad- 
hesion of  the  iris  to  the  capsule  takes  place  along  the  en- 
tire pupillary  margin,  secondary  glaucoma  is  apt  to  de- 
velop and  iridectomy  becomes  necessary ;  in  fact,  any 
adherent  leukoma  may  give  rise  sooner  or  later  to  second- 
ary glaucoma.  Sloughing  of  the  entire  cornea  is  usually 
followed  by  prolapse  of  the  lens,  panophthalmitis  and, 
finally,  phthisis  bulbi. 

The  prognosis  in  all  forms  of  hypopyon-keratitis,  and 
especially  in  serpiginous  ulcer,  is  always  exceedingly  grave, 


164  EXTERNAL  DISEASES  OF  TgE  EYE. 

since  the  entire  cornea  is  threatened  with  destruction. 
unless  appropriate  measures  are  taken  at  the  proper  time, 
the  process  usually  leads  to  total  or  virtual  blindness. 

Treatment. — Asa  prophylactic  measure,  dacryosteno- 
sis  and  conjunctival  catarrh  occurring  in  elderly  people 
should  be  treated  with  special  care,  and  the  subjects 
warned  of  the  danger  that  threatens  them.  Most  cases 
are  presented  too  late  for  general  treatment  to  have  much 
effect;  but  for  all  that  it  must  not  be  neglected  in  pro- 
tracted cases.  The  chief  aim  in  the  management  of  the 
disease  should  be  the  thorough  destruction  of  the  patho- 
genic colonies  in  the  cornea — in  other  words,  disinfection. 
At  the  same  time  the  greatest  care  should  be  exercised  not 
to  destroy  any  more  corneal  tissue  than  is  needful,  because 
extensive  corneal  cicatrices,  even  if  they  do  perforate,  are 
very  apt  to  undergo  distention.  The  first  step  in  this  pro- 
cedure is  direct  disinfection  of  the  ulcer  itself;  the  second, 
the  injection  of  a  saline  solution  under  the  conjunctiva, 
cauterization  of  the  retrotarsal  folds,  etc.,  for  such  is  the 
rapidity  with  which  the  ulcer  tends  to  spread  that  the 
most  energetic  measures  are  demanded.  Still,  every  case 
must  be  treated  on  its  individual  merits.  If  the  case  is 
seen  at  the  very  beginning  of  hypopyon-keratitis  and  pre- 
sents no  more  than  a  yellowish  infiltration  with  a  slight 
tendency  to  ulceration  at  the  center,  painting  with  carbolic 
acid  is  usually  sufficient,  or  even  when  there  is  a  some- 
what more  extensive  infiltration,  about  as  large,  say.  as  the 
one  represented  on  Plate  25,  b,  which  had  already  pro- 
duced hypopyon.  The  eye  is  cocainized  for  this  purpose, 
and  the  carbolic  acid,  after  beincr  slightly  warmed  in  order 
to  melt  it,  applied  to  the  corneal  focus  by  means  of  a 
sharp  probe  wrapped  with  cotton,  until  a  whitish  eschar  is 
formed,  limited  strictly  to  the  diseased  area.  The  eye  is 
then  treated  with  atropin  and  covered  with  a  sealed  band- 
age. If  after  one  or  two  days  the  infiltration  is  still 
found  to  be  progressing,  the  caustic  agent  must  again  be 
applied. 

If  the  infiltration  is  larger  than  the  one  shown   in  the 


DISEASES  OF  THE  CORNEA.  165 

figure,  it  is  fair  to  assume  that  the  bacteria  have  penetrated 
into  the  deeper  layers  of  the  corneal  tissue,  where  they 
cannot  be  reached  by  the  carbolic  acid,  which  only  acts  on 
the  surface.  A  galvanocautery,  drawn  out  to  a  point, 
affords  the  best  means  of  cauterizing  in  this  case,  or  a 
heated  knitting-needle  will  answer  the  purpose  in  an 
emergency.  If  one  margin  of  the  ulcer  has  already 
progressed  further  than  the  others,  cauterization  should  be 
particularly  vigorous  at  that  point.  If  the  situation  of  the 
ulcer  or  of  the  arc  of  propagation  is  such  as  to  justify 
somewhat  less  heroic  measures,  the  infiltrated  tissue  may 
be  scraped  out  as  thoroughly  with  a  sharp-pointed  knife, 
or  a  small  sharp  curette,  and  the  site  touched  with  carbolic 
acid  ;  but  if  on  the  next  or  on  the  third  day  any  part  of 
the  infiltration  is  found  to  have  progressed,  the  thermocau- 
tery must  be  brought  into  requisition  after  all.  This  pro- 
cedure may  be  employed  in  such  cases  as  are  illustrated  on 
Plate  26,  for  example.  [Other  antiseptic  and  caustic  sub- 
stances which  may  be  applied  to  check  the  spread  of  puru- 
lent ulcers  are:  silver  nitrate  (2  per  cent.),  tincture  of 
iodin,  formaldehyd  (1  :  50).  After  curetting  an  ulcer  an 
excellent  practice  is  to  dust  iodoform  upon  its  surface  and 
apply  a  dry  sterile  bandage. — Ed.] 

Another  method  of  treating  these  cases  is  that  advo- 
cated by  Saemisch,  which  consists  in  splitting  the  ulcer. 
The  eye  is  first  thoroughly  cocainized  and  securely  fixed 
with  the  forceps;  a  Graefe  knife  is  inserted  into  the  sound 
tissue  on  one  side  of  the  ulcer,  with  its  cutting-edge  di- 
rected forward,  carried  across  the  anterior  chamber  behind 
the  ulcer,  and  brought  out  on  the  other  side  of  the  ulcer  in 
the  sound  tissue,  so  as  to  divide  it  from  behind  forward. 
The  incision  should  pass  through  the  center  of  the  propa- 
gating arc.  Thus  in  the  case  illustrated  in  Plate  26,  a, 
the  section  would  be  made  from  the  outer  and  lower,  to 
the  inner  and  upper  side  of  the  cornea,  dividing  both 
propagating  arcs.  As  soon  as  the  aqueous  humor,  and 
with  it  the  hypopyon,  is  evacuated,  the  greatly  inflamed 
iris  comes  in  contact   with  the  posterior  surface  of  the 


166  EXTERNAL   DISEASES  OF  THE  EYE. 

cornea  and  causes  violent  pain,  which  lasts  for  some  time. 
W  the  hypopyon  is  tenacious  and  does  not  come  away 
entirely  of  its  own  accord,  it  must  be  removed  with  a  pair 
of  forceps.  If  pus  remains  in  the  anterior  chamber,  it 
need  not  be  removed,  as  it  i-  usually  free  from  germs.  In 
performing  this  operation  the  greatest  care  is  necessary  to 
avoid  injuring  the  lens  with  the  knife.  After  the  first  in- 
cision the  wound  must  he  reopened  every  day  with  a 
blunt,  slender  probe,  until  the  ulcer  begins  to  heal.  The 
advantage  of  this  method  is  that  good  results  are  often 
obtained  at  the  smallest  possible  sacrifice  of  corneal  tis>ue  ; 
on  the  other  hand,  it  cannot  be  denied  that  the  operation 
is  almost  always  followed  by  extensive  anterior  synechia? 
of  the  iris,  which  in  turn  may  give  rise  to  secondary  glau- 
coma. Even  Saemisch's  section  is  inadequate  in  malig- 
nant cases  and  when  the  ulcer  has  reached  a  large  size 
(see  Plate  27). 

This  operation  is  entirely  analogous  to  a  section  car- 
ried through  a  phlegmon  or  furuncle,  from  sound  tissue 
on  one  side  to  sound  tissue  on  the  other,  and  depends 
for  its  good  effects  on  the  same  conditions,  namely, 
relaxation  of  the  tissues  and  the  opening  of  a  chan- 
nel for  the  lymph-stream  to  reach  the  wound  and  check 
the  further  progress  of  microorganisms — in  other  words, 
self-drainage. 

The  treatment  may  be  supplemented  by  injecting  from 
J  to  1  c.c.  of  a  2  to  5  per  cent,  saline  solution  under  the 
conjunctiva,  every  day  or  every  few  days — a  procedure 
which  is  supposed  to  have  a  stimulating  effect  on  the 
lymph-stream.  Above  all,  dacryostenosis  and  conjunc- 
tival catarrh  must  receive  careful  treatment,  the  latter  by 
means  of  daily  applications  of  a  2  per  cent,  solution  of 
silver  nitrate  ;  the  former  by  daily  irrigation  of  the  tear- 
sac  with  a  1  :  1000  sublimate  solution,  and,  if  necessary, 
by  passing  a  sound  or  extirpating  the  sac.  Atropin  is 
also  indicated  to  combat  as  soon  and  as  vigorously  as 
possible  the  iritis  which  is  usually  present.  [A  collyrium 
of  mercuric  chlorid  (1  :  1000)  is,  in  the  judgment  of  the 


DISEASES  OF  THE  CORNEA.  167 

Editor,  too  strong ;  1  :  5000  is  sufficient.     Formaldehyd 
( 1  :  3000)  is  useful.] 

5.  The  Catarrhal  Ulcer. 

This  is  the  most  important  representative  of  the  non- 
purulent group  of  ulcers,  and  is  of  interest  on  account  of 
its  comparative  frequency.  As  its  name  indicates,  it  is  a 
sequel  of  conjunctival  catarrh,  and  usually  occurs  in  old 
people.  It  occupies  the  peripheral  portion  of  the  cornea, 
forming  a  shallow  sulcus  of  variable  length  along  the 
corneal  margin.  As  the  ulcer  presents  very  little  infiltra- 
tion, either  at  the  base  or  along  the  edges,  its  position  and 
extent  are  often  difficult  to  determine  without  an  exam- 
ination of  the  reflecting  properties  of  the  corneal  surface 
or  the  behavior  with  fluorescin  staining.  Pain  is  usually 
moderate,  the  flow  of  tears  and  circumcorneal  redness 
are  not  excessive,  and  the  ulcer  on  the  whole  shows  a  ten- 
dency to  heal  of  itself.  On  the  other  hand,  if  there  is  much 
purulent  secretion,  a  neglected  ulcer  may  develop  into  one 
of  a  purulent  type  and  threaten  perforation.  This  is  a 
grave  complication  on  account  of  the  large  extent  and 
peripheral  position  of  the  ulcer,  and  is  very  apt  to  be 
followed  by  extensive  prolapse  of  the  iris. 

The  diagnosis  is  suggested  by  the  presence  of  ciliary 
congestion.  The  discovery  of  this  type  of  congestion 
during  an  attack  of  catarrh  should  be  immediately  fol- 
lowed by  a  close  scrutiny  of  the  cornea  for  the  presence 
of  such  catarrhal  ulcers.  To  this  end  the  reflecting  power 
of  the  membrane  is  tested  and  an  examination  made  by 
lateral  illumination,  which  affords  the  surest  means  of 
detecting  the  grayish  opacity  (of  the  diseased  cornea)  dur- 
ing the  initial  stage. 

The  prognosis  is  favorable.  The  ulcer  heals  rapidly 
with  appropriate  treatment,  and,  owing  to  its  peripheral 
position,  does  not  affect  the  eyesight. 

Treatment. — This  is  usually  limited  to  the  conjunc- 
tiva.    If  infiltration  makes  its  appearance,  local  disinfect- 


168  EXTERNAL  DISEASES   OF   THE  EYE. 

ants  are   indicated,  one  application    of   sublimate    being 

usually  sufficient. 


INJURIES  OF  THE  CORNEA. 

Injuries  of  the  cornea  demand  the  most  careful  con- 
sideration, not  so  much  on  account  of  their  frequency  as 
of  the  vital  consequences  which  they  may  entail.  The 
slightest  abrasion  of  the  surface  may  open  the  way  to 
infection  and  set  up  a  morbid  process  which  the  surgeon 
is  afterward  unable  to  control.  Foreign  bodies  frequently 
become  embedded  in  the  corneal  surface.  They  may  be 
so  minute  as  to  be  detected  with  great  difficulty,  and  yet 
set  up  an  inflammation  which  by  surrounding  it  with  an 
area  of  grayish  discoloration  betrays  the  site  of  the  for- 
eign body.  When  this  is  a  spicule  of  iron  it  has  a  brown 
or  brownish-black  color.  If  the  iris  is  brown,  such  a 
body  is  at  first  difficult  to  detect ;  later  it  is  brought  out 
more  clearly  by  the  area  of  infiltration,  before  described, 
which  surrounds  it.  Similarly  a  white  substance  (grain  of 
sand,  etc.)  where  the  iris  is  light  colored  can  at  first  only 
be  detected  by  testing  the  reflection  of  the  corneal  surface 
or  with  the  aid  of  lateral  illumination. 

Occasionally  a  non-irritant  body,  such  as  a  grain  of 
powder,  for  example,  which  has  penetrated  below  the 
surface,  may  become  permanently  embedded. 

Stab-  and  cut-wounds,  if  deep  enough,  lead  to  per- 
foration and  prolapse  of  the  iris,  or  at  least  to  adhesion 
of  the  iris  to  the  scar. 

The  treatment  in  all  injuries  of  the  cornea  consists 
in  guarding  against  infection  by  means  of  a  compressing 
bandage.  Foreign  bodies  are  carefully  removed  with  a 
sharp  instrument,  a  cataract-needle,  etc.,  or  with  a  cotton 
pledget  dipped  in  a  sublimate  solution,  if  they  are  situated 
on  the  surface. 

After  the  removal  of  a  foreign  body  the  cornea  should 
be  carefully  examined  with  a  loupe  and  lateral  illumina- 
tion   for  any   stray   particles  that   may   have  been  oyer- 


DISEASES  OF  THE  CORNEA.  169 

looked.  If  the  intruder  was  a  spicule  of  hot  iron,  the 
brown  spot  which  often  remains  (see  Plate  21)  must  be 
carefully  scraped  out  (a  matter  of  some  difficulty  during 
the  first  few  days,  as  the  substance  clings  tenaciously). 
Atropin  is  not  necessary  in  fresh,  non-inflammatory  cases ; 
but  a  compressing  bandage  is  always  to  be  applied  and 
kept  on  until  the  reflex  has  become  normal,  or  at  least 
until  the  site  of  the  injury  becomes  covered  with  epithe- 
lium and  fails  to  take  the  fluorescin  stain.  If  this  pre- 
caution is  neglected,  a  protracted  case  of  diffuse  or  hypo- 
pyon-keratitis is  apt  to  result. 

Large  wounds  of  the  cornea,  especially  perforating 
wounds,  must  also  be  dressed  with  a  compressing  bandage, 
and  the  patient  must  be  put  to  bed.  In  case  of  prolapse 
of  the  iris,  if  the  injury  is  quite  fresh,  replacement  with 
a  suitable  instrument  (spatula)  may  be  attempted,  after 
disinfecting  with  a  1  :  5000  sublimate  solution.  The 
operation  is  usually  a  failure.  If  the  prolapse  is  one  or 
two  days  old,  infection  has  very  probably  taken  place,  and 
replacement  would  be  followed  by  a  dangerous  iritis  which 
would  imperil  the  other  eye.  In  such  a  case  it  is  better, 
therefore,  to  excise  the  prolapsed  iris,  replacing  only  the 
ciliary  attachments,  so  as  to  leave  as  little  iris-tissue  as 
possible  in  the  wound  and  relieve  the  tension  of  the  pupil. 

MALFORMATIONS   OF  THE   CORNEA. 

These  are  of  interest  because  they  interfere  with  vision. 
The  most  frequent  anomaly  is  unequal  horizontal  and 
vertical  curvature,  and  forms  one  of  the  causes  of  astig- 
matism. 

Megalocornea  (cornea  globosa)  may  be  congenital 
and  sometimes  hereditary  ;  the  cornea  may  retain  its  trans- 
parency throughout  the  life  of  the  individual.  A  similar 
anomaly  occurs  after  infantile  glaucoma  ;  but  the  cornea 
in  this  form  early  presents  the  characteristic  glaucomatous 
haze  and  later  becomes  covered  with  irregular  opacities 
which    materially    impair    its    transparency.       The    bulb 


170  EXTERNAL  DISEASES  OE  THE  EYE. 

Plate  28. 

a.  Trachoma,  with  Pannus  of  the  Cornea. -The  patient,  an  Italian 
woman,  37  years  old,  has  suffered  for  years  from  inflammation  of  both 
eyes.  One  eye  shows  incipient  cicatricial  trachoma,  with  a  number  of 
papillary  granulations  on  the  upper  lid.  (The  patient  unfortunately 
(let-lined  to  sit  any  longer  after  the  first  illustration,  and  it  was  impos- 
sible  to  obtain  a  picture  of  the  inner  surface  of  the  upper  lid.  as  had 
been  intended. 

b.  Phthisis  Bulbi  Anterior  ;  Calcareous  Degeneration  of  the  Cornea. 
— The  woman,  who  is  %2i)  years  old,  sustained  a  stab-wound  in  the  right 
eye  when  she  was  five  years  old;  the  scar  is  plainly  seen,  running 
obliquely  toward  the  corneal  margin.  She  does  not  remember  ever 
to  have  been  able  to  see  with  this  eye.  The  contraction  of  the  anterior 
portion  of  the  eyeball  suggests  that  traumatic  cyclitis  occurred  at  the 
time.  As  the  remains  of  iritis  are  to  be  seen  in  the  other  eye,  it  is  quite 
likely  that  there  was  also  sympathetic  iritis,  which,  strangely  enough, 
appears  to  have  healed  spontaneously,  for  the  patient  does  not  remember 
to  have  suffered  from  inflammation  in  the  left  eye.  The  cornea  of  the 
right  eye  was  shrunken,  and  badly  disfigured  with  whitish  epithelial 
scales.  Tattooing  was  employed  with  very  good  results  and  without 
doing  any  damage. 

c.  Parenchymatous  Keratitis. — The  inflammation  began  three  weeks 
ago,  and  the  cornea  is  already  to  a  large  extent  covered  with  an  opacity 
which  began  at  the  upper  and  outer  margin.  The  opacity  was  soon 
followed  by  marked  vascularization.  That  the  keratitis  is  diffuse  is 
recognized  by  the  ill-defined  delimitation  of  the  infiltrated  area.  Cause, 
hereditary  syphilis. 


gradually  yields  to  the  increased  tension,  and  unless  the 
latter  is  relieved  the  condition  usually  ends  in  blindness. 
KeratocontlS  is  an  acquired  anomaly,  in  which  the 
cornea  assumes  a  eonieal  shape.  The  center  of  the  cornea 
becomes  thinner  and  is  gradually  bulged  forward  by  the 
intraocular  pressure.  A  severe  grade  of  keratoconus  is 
at  one«-  recognized  by  the  altered  reflex,  which  lends  a 
peculiar  flashing-look  to  the  eye.  The  light  is  concen- 
trated on  the  apex  of  the  cone;  the  reflex  is  smaller 
and  brighter  than  in  the  normal  eye,  and  surrounded 
by  a  halo.  Doubtful  eases  are  best  examined  with  a 
Placidodisc,  tin-  black  and  white  concentric  rings  of 
which  show  a  peculiar  distortion.  Similar  distortions 
and  illusive  movements  are  also  observed  in  the  ophthal- 


Tab.  28. 


a 


lith.Anst  F.  Reich  hold.  München. 


DISEASES  OF  THE  SCLERA.  171 

moscopic  image.  Jn  advanced  cases  of  keratoconus  the 
apex  becomes  opaque  and  another  disturbing  element  is 
added  to  the  abnormal  refractive  phenomena.  Both  eyes 
are  usually  affected,  and  the  condition  is  met  with  most 
frequently  among  women.  It  is  rarely  possible  to  correct 
the  optical  error  with  glasses.  I  once  saw  the  process 
arrested  by  sclerotomy,  supported  by  general  constitutional 
treatment.  [High  grades  of  conical  cornea  cannot  be 
helped  much  if  at  all  with  glasses;  but  intermediate 
grades,  and  even  cases  of  considerable  conicity,  may  be 
markedly  benefited  and  vision  greatly  improved  with  high 
cylinders  or  spherocylindrical  combinations.  The  best 
operative  procedure  is  cauterization  of  the  apex  of  the 
cone  with  the  galvanocautery  and  later,  if  necessary,  an 
optical  iridectomy. — Ed.] 

Staphyloma  may  develop  in  consequence  of  extensive 
ulceration  of  the  cornea  and  lead  to  grave  impairment  of 
the  visual  power.  The  deformity  is  caused  by  the  disten- 
tion of  scar-tissue  and  is  almost  always  associated  with 
heightened  intraocular  tension — secondary  glaucoma. 
Irremediable  blindness  is  the  usual  result,  and  the  only 
treatment  is  a  surgical  operation. 


DISEASES   OF   THE   SCLERA. 

i.  Inflammation  of  the  Sclera. 

Inflammatory  processes  are  much  less  common  in  the 
sclera  than  in  the  cornea,  and  are  always  localized  in  the 
anterior  segment.  Two  forms  are  distinguished  :  super- 
ficial, or  episcleritis,  and  deep  scleritis.  Many  transitional 
forms  are  also  met  with,  and  it  is  often  difficult  to  deter- 
mine to  what  depth  the  inflammation  has  penetrated. 
Both  forms  are  characterized  by  the  formation  of  circular, 
hypertrophic  nodules  ;  in  deep  scleritis,  however,  the  in- 
flammatory process  is  prone  to  diffuse  itself  over  a  larger 
area,  surrounding  the  cornea  on  all  sides  and  producing 


172  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  29. 

a.  Scleritis,  recent — i.  <•.,  three  weeks  old.  The  back-shaped  elevation, 
which  is  plainly  visible  to  the  temporal  side  of  the  cornea,  is  very  sensi- 
tive to  pressure.  The  disease  was  probably  rheumatic  in  character  and 
took  two  months  to  heal,  leaving  a  slaty  discoloration  at  the  site  of  the 
elevation,  which  may  be  seen  over  the  cornea  in  the  next  figure. 

h.  Sequelae  of  Scleritis  and  Sclerotizing  Keratitis.— It  is  quite  evident, 
from  the  pronounced  slaty  discoloration  and  reduced  density  of  the 
sclera  above  the  cornea,  that  the  patient  (a  woman,  37  years  old)  has  suf- 
fered tor  years  from  scleritis.  The  actual  presence  of  scleritis  at  that 
point  and  to  the  temporal  side  of  the  cornea  may  be  inferred  from  the 
inflammatory  opacity  in  the  cornea  and  corresponding  ciliary  congestion. 
It  is  also  evident  from  the  haziness  of  the  corneal  margin  that  the  cornea 
has  suffered  frequent  encroachments  during  former  attacks  of  scleritis 
(sclerotizing  keratitis).  Finally,  we  see  signs  of  a  former  plastic  iritis  in 
the  irregular  outline  of  the  pupil,  which  is  attached  to  the  lens  by  nu- 
merous synechias.  The  only  abnormality  in  the  other  eye  is  a  broad 
synechia  in  the  inner  and  lower  portion.  The  cause  of  the  process  is 
difficult  to  determine.  The  irritative  symptoms  began  when  the  patient 
was  fourteen  years  old.  She  has  eight  healtby  children  ;  two  of  her 
brothers  died  of  phthisis.  Eleven  years  ago  she  had  a  short  attack  of 
articular  rheumatism  without  fever.  Her  eyes  had  not  troubled  her  for 
the  past  three  years  ;  the  present  inflammation  began  six  weeks  ago  after 
confinement.  Not  a  trace  of  albumin  in  the  urine.  Iridectomy.  Dis- 
charged with  visual  acuity  of  the  left  eye  equal  to  ^. 


first  a  bluish-red,  and  later  a  pale  violet,  porcelain-like 
discoloration  (Plate  29,  b).  A  dee))  scleritis  often  en- 
croaches on  the  cornea,  where  it  produces  infiltrations  in 
the  deeper  layers  which  do  not  break  down,  but  usually 
leave  a  permanent  opacity  (sclerotizing  keratitis).  Besides 
the  cornea,  the  iris  and  choroid  coat  are  very  liable  to  be- 
come involved  ;  opacities  are  formed  in  the  vitreous  body 
and  threaten  to  destroy  the  eyesight.  Finally,  not  to 
mention  iritic  exudates,  circular  synechia?,  or  pupillary 
membranes,  the  process  may  eventually  lead  to  cataract 
and  ectasia  sclerse,  when  the  membrane  is  weakened  by  a 
prolonged  attack  of  the  disease. 

\\  e  speak  of  a  scleral  staphyloma,.  This  form  of  scler- 
itis usually  attacks  both  eyes,  preferably  those  of  young 
individuals  of   the  female  sex.     Such  patients  are  often 


Tab.  29. 


I  9' 


f   *  \ 


m&r 


' 


LühuAnst  F.  Reichhold,  München, 


DISEASES  OF  THE  SCLERA.  173 

tuberculous  or  the  subjects  of  hereditary  or  acquired 
syphilis.  The  disease,  which  usually  lasts  for  years,  is 
rarely  amenable  to  treatment. 

Episcleritis  is  more  common  than  the  deep  form,  and  is 
characterized  by  the  scleritic  hump  (Plate  29,  a)  which 
betrays  its  site  by  a  deep,  bluish- red  injection  underneath, 
which  is  not  movable  with  the  conjunctiva.  The  inflamma- 
tory foci  never  ulcerate,  but  gradually  disappear  in  from 
five  to  ten  weeks  or  later,  leaving  a  dull  gray  spot  due  to 
the  attenuation  of  the  scleral  tissue.  Episcleritis  is  also 
refractory  to  treatment,  especially  the  migrating  form, 
which  tends  to  encircle  the  cornea  wholly  or  partially — 
scleritis  migrans. 

The  elevations  in  the  sclera,  which  represent  a  true 
round-cell  infiltration,  vary  in  size  from  3  to  8  mm.  ; 
several  may  be  present  in  the  same  eye.  They  are  usually 
very  sensitive  to  pressure,  but  not  painful  if  undisturbed, 
except  In  a  few  cases,  when  the  pain  is  said  to  be  very  dis- 
tressing. The  process  is  very  apt  to  recur,  and,  in  course 
of  time,  attacks  both  eyes.  Episcleritis  is,  on  the  whole, 
less  dangerous  than  the  deep  form,  and  is  followed  by 
fewer  complications. 

Tuberculosis  and  syphilis  are  predisposing  causes ;  but 
the  affection  is  more  often  observed  in  connection  with  the 
rheumatic  diathesis,  and  the  treatment  in  most  cases  should 
consist  of  active  antirheumatic  remedies:  sweating  and  a 
long-continued  use  of  sodium  salicylate. 

2.  Injuries  of  the  Sclera. 

In  addition  to  stab-  and  cut-wounds,  which  are  quite 
common,  we  occasionally  see  the  more  serious  injury  of 
rupture  of  the  sclera,  caused  by  the  application  of  violent 
external  force — a  blow  with  the  fist  or  a  stick,  or  a  cow's 
horn,  or  collision  with  any  blunt  object.  Rupture  of  the 
sclera  is,  of  course,  a  perforating  wound,  and  therefore 
endangers  the  contents  of  the  globe  ;  the  same  is  true, 
however,  of  most  stab-  and  cut-wounds.     Besides  causing 


174  EXTERNAL  DISEASES  OF  THE  EYE. 

the  loss  of  more  or  less  vitreous  body,  such  perforating 
wounds  are  the  means  of  introducing  infectious  material 
into  the  interior  of  the  globe,  and  as  the  latter  is  an  ex- 
cellent culture-medium,  the  purulent  inflammation  rapidly 
spreads  to  the  retina  and  uveal  tract.  In  exceptional 
cases  rupture  of  the  sclera  takes  place  without  tearing  the 
conjunctiva,  so  that  the  rent  does  not  communicate  with 
the  outside.  In  such  cases  the  lens,  instead  of  being 
forced  completely  through  the  rent,  as  it  usually  is,  may 
only  prolapse  as  far  as  the  conjunctiva  (Plate  34,  b).  Kupt- 
ure  usually  takes  place  above  the  cornea,  in  a  line  parallel 
to  the  margin  ;  sometimes  to  one  side  of  the  cornea  (Plate 
34,  h).  The  accident  is  very  often  followed  by  a  large 
hemorrhage  into  the  vitreous — hemophthalmos — the  retina 
becomes  seriously  involved  (retinitis  proliferans),  and  total 
or  partial  blindness  usually  results.  A  large  escape  of 
vitreous,  especially  if  mixed  with  blood,  is  followed  sooner 
or  later  by  separation  of  the  retina  and  total  bliildness. 

Wounds  inflicted  with  a  knife,  scissors,  or  broken  glass 
may  heal  satisfactorily,  if  they  do  not  become  septic  ;  they 
are  not  attended  with  as  great  a  loss  of  vitreous  as  is  a 
rupture  caused  by  compression  of  the  bulb. 

A  forei(/n  body  is  not  as  likely  to  bury  itself  in  the 
sclera  as  it  is  in  the  cornea  ;  it  usually  penetrates  into  the 
globe  and  lodges  in  the  vitreous  or  on  the  retina.  This  is 
particularly  the  case  with  pieces  of  iron,  which  acquire 
sufficient  momentum  to  pierce  the  tissues  of  the  sclera. 
Pieces  of  copper  also,  from  exploding  dynamite  caps,  chips 
of  stone  scattered  by  powder  or  dynamite  blasting,  and 
glass  splinters  from  the  explosion  of  glass  vessels  in  labo- 
ratory work,  etc.,  often  penetrate  the  sclera.  [f  the 
splinter  is  large,  it  may  inflict  a  considerable  wound  with- 
out remaining  in  the  globe;  these  cases  are  rare,  however, 
compared  with  those  in  which  the  splinter  penetrates  into 
the  interior  of  the  globe  ;  and  the  latter  event  is  always  to 
!><■  considered  the  most  likely  in  making  a  diagnosis. 

A  perforating  wound  of  the  sclera,  if  extensive  and 
before  the  edges  have  become  united,  reveals  itself  by  re- 


DISEASES  OF  THE  SCLERA.  175 

duction  in  the  tension  of  the  globe.  The  ophthalmoscope 
shows  more  or  less  hemorrhage  and  inflammatory  turbidity 
in  the  vitreous  body.  If  the  wound  is  situatetl  along  the 
equator,  a  bright  band  may  be  seen  in  the  ophthalmoscopic 
image,  indicating  a  lesion  of  the  choroid.  The  presence 
of  a  foreign  body  in  the  interior  of  the  globe  demands  a 
thorough  ophthalmoscopic  examination.  If  the  suspected 
substance  is  iron,  it  is  advisable  to  use  the  sideroscope,  a 
very  delicate  magnetic  needle  provided  with  a  device 
which  permits  its  deviations  to  be  read  off  with  a  tele- 
scope, or  the  large  electromagnet,  proposed  by  me,  which 
either  attracts  the  splinter  toward  the  iris  or  at  least  indi- 
cates the  presence  of  iron  by  the  pain  it  produces.  [The 
Röntgen  rays  furnish  a  means  by  which  the  presence  and 
position  of  a  foreign  body  in  the  eye  can  be  determined 
with  accuracy.  Of  the  many  methods  suggested  for  em- 
ploying the  X-rays  under  these  circumstances,  that  one 
proposed  by  W.  M.  Sweet  seems  to  the  Editor,  who  speaks 
from  experience,  to  be  the  best,] 

Never  explore  a  wound  hi  tlte  sclera  with  a  probe, 
either  for  the  purpose  of  detecting  a  suspected  foreign 
body  or  to  determine  whether  the  wound  is  really  a  per- 
forating one.  For  in  doing  so  there  is  great  danger  of  in- 
troducing pathogenic  germs,  which  may  be  present  on  the 
exterior  of  the  wound,  into  the  vitreous  body  and  setting 
up  a  fatal  inflammatory  process  in  the  interior  of  the 
globe. 

The  treatment  of  scleral  wounds  demands  absolute  rest 
in  bed,  at  least  for  some  time.  If  the  wound  is  large,  both 
eyes  must  be  bandaged.  If  the  wound  is  already  closed,  it 
is  better  not  to  disturb  it ;  gaping  wounds  may  be  care- 
fully closed  with  sutures  passing  through  the  conjunctiva 
and  episcleral  tissue  ;  it  is  not  usually  advisable  to  in- 
clude the  sclera  itself  in  the  sutures. 

Only  when  the  piece  of  iron  which  has  penetrated  the 
sclera  is  very  large  should  the  attempt  be  made  to  extract 
it  through  the  scleral  wound  with  an  electromagnet ;  small 
splinters  should  be  drawn  into  the  anterior  chamber  and 


17l)  EXTERNAL   DISEASES  OF  THE  EYE. 

Plate  30. 

".  Sarcoma  of  the  Iris. — I  am  indebted  for  this  picture  to  the  kind- 
ness of  my  colleague,  Dr.  Mayweg,  of  Hagen,  -who  made  the  following 

report  of  the  case  before  the  Ophthalmologic  Society  of  Heidelberg,  at 
the  meeting  of  the  society  in  isl»7.  As  long  ago  as  1870  the  patient,  a 
factory-hand.  .">:;  years  old,  had  his  attention  called  to  a  small  yellowish- 
brown  elevation,  as  large  as  a  pinhead,  in  the  temporal  third  of  the  iris, 
near  the  outer  rim.  A  year  later  he  noticed  a  change  in  the  spot;  it 
gradually  became  larger,  without  causing  diminution  of  vision,  which 
at  the  time  of  his  admission  was  perfectly  normal.  The  tumor  was  com- 
pletely removed  in  two  sittings  and  the  wound  healed  in  three  weeks. 
Examination  of  the  tumor  revealed  a  moderately  pigmented,  spindle- 
cell  sarcoma.  The  pigment-spots  on  the  lower  portion  of  the  iris  are  not 
pathologic  ;  such  spots  are  often  seen  on  the  iris  ;  occasionally,  however, 
they  develop  into  sarcoma. 

b.  Syphilitic  Iritis.— There  is  marked  ciliary  congestion.  The  hyper- 
emia in  the  iris  has  changed  the  original  blue-gray  color  (as  seen  in  the 
other  eye  in  Fig.  C)  to  a  greenish  tint.  The  pupil  is  dilated  with  atropin 
and  shows  the  projecting  synechia?.  The  patient  complains  of  pain  and 
a  moderate  degree  of  photophobia;  he  was  infected  a  few  years  ago. 

removed  through  an  incision  in  the  cornea.  AVhen  the 
eve  is  brought  near  the  electromagnet,  if  there  is  a  loose 
piece  of  iron  in  any  part  of  the  vitreous  body  it  will  be 
drawn  around  the  lens  against  the  iris  and  cause  it  to 
bulge  forward.  As  soon  as  this  is  observed  the  patient's 
head  is  at  once  thrown  back,  or  the  electric  current  inter- 
rupted, lest  the  substance  become  fixed  in  the  posterior 
surface  of  the  iris.  If  the  eye  is  now  turned  toward  the 
site  of  the  intruder,  it  can  usually  be  drawn  through  the 
pupillary  opening  into  the  anterior  chamber,  if  the  pre- 
caution has  been  taken  to  dilate  the  pupil  before  beginning 
the  operation.  If  the  substance  is  lodged  in  the  retina 
or  choroid  coat,  some  time  may  elapse  before  the  magnet 
becomes  effective,  hence  the  attempt  must  not  be  aban- 
doned too  soon  and  may  be  repeated  if  necessary.  The 
smaller  the  particle  of  iron  the  greater  must  be  the  power 
of  the  magnet,  and  rh-<  versa,  li'  there  is  no  large  mag- 
net at  hand,  an  attempt  must  be  made  to  find  and  extract 
the  foreign  body  with  the  small  magnetic  probe,  either 
through  the  original  scleral  wound,  or  through  a  fresh  in- 


Tab.  30. 


'  üB^ 


<a 


A 


lith.  Anst  F.  Hcuhhold.  Miüirten. 


DISEASES  OF  THE  IRIS  AND   CILIARY   BODY.     177 

cision.  [If  the  foreign  substance,  steel  or  iron,  is  prop- 
erly  located  by  means  of  skiagraphic  examination,  the 
Editor  believes  that  its  extraction  through  a  suitably  placed 
incision  by  means  of  the  extension  point  of  a  Hirschberg 
or  similar  magnet  is  an  eminently  proper  surgical  pro- 
cedure.] 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY, 
i.  Inflammation. 

As  a  rule,  the  anterior  segments  of  the  uvea,  the  iris, 
and  the  ciliary  body  all  participate  in  the  inflammatory 
process,  so  that  inflammation  of  the  iris  alone  (iritis)  or  of 
the  ciliary  body  (cyclitis)  is  not  very  common  ;  in  severe 
grades  of  inflammation  even  the  choroid  becomes  involved, 
and  we  speak  of  n  reit  is. 

The  Symptoms  of  iritis  are  very  characteristic.  There 
is  pericorneal  injection,  and  the  pain,  lachrymation,  and 
photophobia  are  so  severe  that  the  patient  finds  it  difficult 
or  impossible  to  open  his  eyes  in  a  bright  light.  Hyper- 
emia is  a  conspicuous  symptom,  which  manifests  itself  in 
chromatic  alterations  in  the  iris  ;  a  blue  iris  becomes  green, 
gray  changes  to  a  reddish  tint,  a  light  brown  or  green 
color  is  somewhat  darker  and  more  muddy  than  that  of 
the  normal  eye  (Plate  30;  b).  The  striatums  are  partially 
obscured  ;  the  tissues  are  somewhat  turbid  and  puckered 
or  thickened  from  the  inflammatory  infiltration.  The  in- 
crease in  the  volume  of  the  iris  causes  shrinking  and  par- 
tial loss  of  mobility  in  the  pupil.  The  latter  symptom  is 
aggravated  by  the  inflammatory  irritation  in  the  muscle- 
fibers,  and  eventually  the  pupil  fails  to  react  promptly  to 
light  on  account  of  attachments  between  the  pupillary 
margin  and  the  lens  capsule.  At  first  certain  portions 
only  of  the  pupillary  margin  become  attached,  which, 
after  dilatation  of  the  pupil  with  a  mydriatic  (atropin, 
hyoscin,  Cocain,  homatropin),  appear  as  tongue-shaped 
12 


178  EXTERNAL   DISEASES  OF   THE  EYE. 

projections  of  varying  width  (Plate  30,  h)  and  mar  the 
circular  outline  of  the  pupil.  These  attachments  are 
called  'posterior  synechias,  to  distinguish  them  from  antei  ior 
synechia?  between  the  iris  and  the  cornea,  which  occur  in 
perforations  of  the  cornea.  If  the  case  is  seen  late,  the 
entire  pupillary  margin  may  be  bound  down  and  the  pupil 
may  fail  to  dilate  altogether  under  the  influence  of  a  myd- 
riatic. Sometimes  the  pupil  begins  to  dilate  at  various 
points  after  a  long  application  of  the  drug,  by  the  freshly 
formed  synechias  giving  way,  and  if  the  attachments  are 
not  too  old  it  is  sometimes  possible  to  loosen  them  all  in 
this  way  and  restore  the  contour  of  the  pupil.  The  at- 
tachment of  the  whole  pupillary  margin  by  an  annular 
synechia  is  termed  exclusion  of  the  pupil  (seclusio  pupillae), 
because  the  space  behind  the  iris,  the  posterior  chamber, 
is  excluded  from  the  anterior  chamber. 

If  numerous  synechia?  are  formed,  they  are  usually  asso- 
ciated with  exudation  into  the  pupillary  region  and  the 
formation  of  a  false  membrane  which  completely  occludes 
the  pupil ;  this  is  called  occlusion  of  the  pupil  (occlusio 
pupillae).  The  interference  with  vision  is  directly  propor- 
tional to  the  thickness  of  the  membrane.  At  the  same 
time  a  similar  exudation  takes  place  in  the  aqueous  humor, 
which  becomes  turbid  with  leukocytes  and  fibrin,  and 
leads  to  still  greater  obscuration  of  the  iris  and  pupil. 
In  severe  grades  the  leukocytes  may  collect  at  the  bottom 
of  the  anterior  chamber,  forming  a  hypopyon  and  thus  in- 
dicating the  purulent  nature  of  the  iritis.  In  other  cases 
the  exudate  consists  principally  of  fibrin  and  forms  a 
semitransparent  grayish  opacity  in  the  anterior  chamber. 
High  grades  of  iritis  usually  give  rise  to  a  diffuse  hazi- 
ness of  the  cornea,  due  partly  to  fine  deposits  on  its  pos- 
terior surface,  and  partly  to  direct  participation  in  the  in- 
flammatory process  in  the  form  of  an  infiltration  of  migra- 
tory leukocytes. 

The  pain  in  severe  iritis  is  often  very  great,  and  spreads 
from  the  eye  to  the  brow  and  temple;  it  becomes  almost 
unbearable  if  the  eye   i-   exposed    to   the    light  ;   but   may 


DISEASES  OF  THE  WIS  AND   CILIARY  BODY.     179 

also  be  very  severe  at  night,  when  it  gives  rise  to  exces- 
sive  lachrymation. 

On  the  other  hand,  there  are  insidious  cases  of  iritis,  in 
which  the  patient  is  hardly  conscious  of  inflammation  ; 
persons  are  sometimes  found  to  have  synechia?  who  do  not 
remember  ever  to  have  had  inflamed  eyes. 

Iritis  may  be  present  in  one  eye  only  ;  and,  if  it  recurs, 
attacks  the  same  eye ;  or  it  may  show  a  tendency  to  affect 
both  eyes,  so  that  the  second  eye  becomes  involved  sooner 
or  later. 

Cyclitis  presents  other  manifestations  of  inflammatory 
exudation  : 

1.  Precipitates  on  the  posterior  lamina  of  the  cornea, 
ranging  in  size  from  a  mere  point  to  2  mm.,  consisting  of 
circular  accumulations  of  round  cells,  mixed  with  pigment 
or  fibrin,  gray  or  brown  in  color,  according  to  the  nature 
of  the  pigment.  They  are  seen  chiefly  on  the  lower  por- 
tion of  the  cornea  and  may  be  so  minute  as  to  be  detected 
only  with  the  aid  of  a  loupe  and  lateral  illumination,  or 
with  the  ophthalmoscope  under  direct  light.  They  are 
often  limited  to  the  inferior  quadrant  of  the  cornea — i.  c, 
to  a  triangular  area,  the  apex  of  which  lies  in  the  pupil. 
The  exudation  in  cyclitis  may  also  take  the  form  of  hypo- 
pyon or  deposit  grayish-white  masses  which  appear  float- 
ing in  the  inferior  and  lateral  portions  of  the  anterior 
chamber. 

2.  The  exudation  may  be  principally  into  the  posterior 
chamber  and  produce  a  general  attachment  of  the  surface 
of  the  iris  to  the  lens-capsule  by  a  complete  posterior 
synechia.  This  is  recognized  by  the  gradual  retraction  of 
the  iris  against  the  border  of  the  lens  as  the  exudate  con- 
tracts, and  the  deepening  of  the  anterior  chamber  at  its 
periphery.  In  this  form  of  ciliary  attachment  dilatation 
of  the  pupil  is  complete,  or  absent  altogether. 

3.  The  exudate  may  occupy  the  vitreous  chamber,  es- 
pecially the  anterior  portion,  and,  if  extensive,  produce 
more  or  less  marked  impairment  of  the  visual  power. 
The  exudate  behind  the  lens  in  course  of  time  becomes 


180  EXTERNAL   DISEASES  OF  THE  EYE. 

organized  into  masses  of  inflammatory  tissue  which  gradu- 
ally contract,  while  the  continuous  irritation  of  the  ciliary 
body  and  progressive  obscuration  of  the  vitreous  finally 
lead  to  atrophy  of  the  eyeball  (phthisis  bulbi). 

In  severe  grades  of  cyclitis  the  three  forms  of  exuda- 
tion may  be  combined,  and  severe  inflammatory  symptom-, 
especially  pain  and  congestion,  are  present.  On  the  other 
hand,  a  simple  cyclitis  may  run  its  course  without  giving 
rise  to  pain  and  congestion,  being  recognized  only  by  the 
presence  of  precipitates  and  turbidity  of  the  vitreous  and 
by  the  interference  with  vision  which  these  alterations 
produce.  The  term  serous  iritis  was  formerly  given  to 
this  variety  ;  but  the  name  is  incorrect  and  now  obsolete. 

Alteration  of  the  intraocular  pressure  is  an  important 
symptom  of  cyclitis.  It  may  be  abnormally  high,  in  the 
form  characterized  by  the  deposition  of  precipitates,  or  it 
may  fall  below  the  normal,  especially  in  severe  grades  of 
the  disease  and  in  the  later  stages.  Associated  with  ab- 
normally diminished  tension  we  often  have  the  important 
subjective  symptom  of  extreme  sensitiveness  to  pressure 
in  the  ciliary  region,  the  patient  immediately  drawing  his 
head  back  when  we  attempt  to  touch  this  region.  Another 
ominous  symptom  of  cyclitis  is  edema  of  the  upper  lid. 

Iridocyclitis ,  or  the  association  of  cyclitis  and  iritis, 
constitutes  a  dangerous  and  very  intractable  disease,  ow- 
ing to  the  permanent  injuries  to  the  eye  inflicted  by  the 
cyclitic  exudates  in  the  posterior  chamber  and  in  the 
vitreous,  which  are  absorbed  with  great  difficulty  and 
cannot  be  removed  by  surgical  means.  The  cyclitis  shows 
a  decided  disinclination  to  heal,  and  may  torture  the 
patient  for  months  and  years.  But  even  a  simple,  chronic 
cyclitis,  producing  mere  punctiform  precipitates  on  the 
cornea  and  a  moderate  degree  of  turbidity  in  the  vitreous, 
may  run  a  slow  and  tedious  course.  When  primary  it 
usually  attacks  both  eyes.  In  cases  of  long  duration  the 
choroid  usually  becomes  involved. 

While,  therefore,  even  an  acute  iritis  or  iridocy- 
clitis may  be  protracted   for  weeks,   the  duration  of  the 


DISEASES   OF  THE  IRIS  AND   CILIARY  BODY.     181 

chronic  form  must  be  expressed  in  months  or  years,  and 
the  final  result  is  but  too  often  practical  or  total  blindness, 
the  more  so  if  the  disease  shows  a  tendency  to  relapses,  as 
it  often  does.  Chronic  iritis  and  iridocyclitis  eventually 
lead  to  atrophy  of  the  iris,  cataract,  atrophy  of  the  bulb, 
either  of  its  anterior  portion  [phthisis  anterior)  or  of  its 
entire  volume  (  phthisis  bulbi). 

The  causes  of  iritis  and  iridocyclitis  are  manifold. 
We  distinguish  between  primary  and  secondary  iritis. 
The  latter  occurs  in  keratitis,  especially  in  the  purulent 
form,  and  after  seleritis,  choroiditis,  retinal  detachments, 
intraocular  tumors,  etc. 

The  primary  form  may  follow  in  the  train  of  various 
constitutional  diseases,  or  it  may  occur  as  a  localized  dis- 
order, as  in  traumatism.  Syphilis  is  by  far  the  common- 
est cause  of  iritis  and  iridocyclitis  (in  about  one-half  of 
all  the  cases). 

Syphilitic  iritis  may  assume  the  form  of  a  simple  iritis 
with  synechia?  (Plate  30,  b) ;  or  it  may  be  attended  with 
more  or  less  extensive  deposits  on  the  cornea,  or  both  these 
forms  may  be  combined.  Not  uncommonly  the  disease 
presents  a  characteristic  picture  by  the  formation  of  nod- 
ules in  the  tissues  of  the  iris  (Plate  31).  The  color  of 
these  nodules  when  they  are  small  (1  mm.)  is  grayish-red  ; 
when  they  are  large  (3  or  4  mm.)  yellowish-red,  and  the 
surrounding  portion  of  the  iris  is  usually  congested  and 
reddened.  They  preferably  select  the  pupillary,  more 
rarely  the  ciliary,  margin,  and  grow  quite  rapidly.  Occa- 
sionally several  appear  together,  and  by  coalescing  convert 
portions  of  the  pupillary  margin  into  a  thick  fold.  The 
site  of  such  a  syphiloma  is  invariably  marked  by  a  syn- 
echia, which  persists  even  after  the  nodules  have  become 
absorbed.  Any  marked  thickening  of  the  pupillary  mar- 
gin, associated  with  an  extensive  synechia?,  should  arouse  a 
suspicion  of  the  specific  nature  of  the  inflammation,  even 
if  the  nodules  are  not  plainly  visible,  as  they  often  require 
the  microscope  for  their  detection. 

Iritis,  with  or  without  the  formation  of  nodules,  usually 


182  EXTERNAL   DISEASES  OF  TUE  EYE. 

Plate  31. 

Syphilitic  Condylomatous  Iritis.  J..  P.,  23  years  old,  footman.  The 
patient  complains  of  pains  in  the  right  temporal  region  and  in  tin-  right 
eye  for  the  past  five  days.  Ciliary  injection  :  cornea  and  aqueous  humor 
normal;  pupil  dilates  in  the  form  of  a  kidney  upon  instillation  of  atro- 
pin,  owing  to  a  synechia  at  the  outer  lower  portion.  At  this  point  a 
reddish  tumor  as  large  as  a  hemp-seed  projects  into  the  pupil.  On  the 
raphe  of  the  penis,  about  the  middle  of  the  pendulous  portion,  is  a  mod- 
erately infiltrated,  pigmented  scar  id'  a  livid  coppery  hue,  ahout  as  large 
as  a  bean.  Inguinal,  cervical,  and  axillary  glands  swollen.  Diffuse 
pustular  Syphilide. 

(und  with  inunctions  and  subconjunctival  injections  of  sublimate. 


appears  in  the  secondary  stage  of  syphilis,  so  that  the 
syphilomata  might  with  propriety  be  termed  papules.  If, 
as  rarely  happens,  it  appears  after  the  first  year  of  the 
disease,  the  nodules  may  be  wanting,  or  they  may  appear 
during  the  tertiary  stage,  when  they  should  be  designated 
as  gummato.  They  may  attain  to  a  eonsiderable  size  and 
involve  the  ciliary  body. 

In  the  course  of  a  syphilitic  infection  iritis  is  very  apt 
to  develop  in  both  eyes;  it  is  prone  to  recur,  and  is  often 
accompanied  by  disease  of  the  choroid,  retina,  and  optic 
nerve. 

Iritis  may  1  >e  attributable  to  hereditary  syphilis.  Chronic, 
bilateral  iritis,  occurring  in  a  child,  always  suggests  hered- 
itary syphilis. 

Rheumatic  iritis  is  quite  common  in  certain  districts. 
It  presents  no  characteristic  symptoms,  and  the  diagnosis 
must  be  based  on  evidences  of  rheumatic  disease  in  other 
parts  of  the  body,  on  the  history,  and  on  the  effect  of 
drugs.  Relapses  are  frequent  ;  they  often  follow  relapses 
of  articular  rheumatism. 

Gonorrheal  iritis,  occurring  as  it  does  in  gonorrheal  sub- 
jects who  are  apt  to  suffer  from  so-called  gonorrheal  rheu- 
matism, is  often  difficult  to  distinguish  from  the  rheumatic 
form.  The  same  tendency  to  appear  in  association  with 
articular  rheumatism,  or  with  relapses  of  the  same,  is  ob- 
served in  this  type.     It  often  proves  very  intractable. 


Tab    31. 


■ 


LWi . Änst  E  Reichhold,  München 


DISEASES  OF  THE  IRIS  AND   CILIARY  BODY.    183 

Among  the  rarer  forms  of  iritis  may  be  mentioned  tuber- 
culous and  scrofulous  iritis,  which  occurs  in  tuberculous 
subjects  either  as  a  simple  iritis  with  posterior  precipitates, 
or  as  a  chronic  tubercular  process  with  the  formation  of 
nodules  in  the  tissues  of  the  iris.  The  latter  somewhat 
resemble  syphilomata  ;  but  they  are  situated  at  the  periph- 
ery, instead  of  at  the  pupillary  margin,  and  their  color 
is  more  gray  or  grayish-red.  Their  growth  is  less  rapid 
than  that  of  syphilomata  and  is  attended  with  less  inflam- 
matory symptoms ;  usually  they  are  associated  with  large 
precipitates  on  the  posterior  layer  of  the  cornea.  A  num- 
ber of  smaller  nodules  often  coalesce  and  form  an  irregu- 
lar, lumpy  mass,  which  partially  fills  the  anterior  chamber. 
The  process  preferably  begins  in  the  lower  portion  of  the 
anterior  chamber.  The  presence  of  miliary  tubercles 
among  the  larger  spherical  proliferations  in  the  iris  some- 
times helps  to  clear  up  the  diagnosis.  Small  nodules  re- 
sembling tubercles  may  also  be  caused  by  the  entrance 
of  cilia  into  the  anterior  chamber  and,  rarely,  by  leukemia 
and  pseudoleukemia. 

Iritis  is  occasionally  met  with  in  diabetes  and  albumin- 
uria, or  in  connection  with  recurrent  fever. 

Idiopathic  iritis,  or  one  in  which  no  primary  disease 
can  be  discovered,  is  not  attended  with  marked  inflam- 
matory symptoms.  It  occurs  usually  in  the  form  of  a 
chronic  iridochoroiditis  with  synechia?,  deposits,  and  dis- 
ease of  the  deep  layers  of  the  vitreous,  which  becomes 
more  and  more  turbid.  It  leads  to  obscuration  of  the 
lens  and  atrophy  of  the  choroid  and  retina,  and  may  in 
the  course  of  years  result  in  complete  blindness.  Idio- 
pathic iritis  is  a  grave  disease,  which  usually  affects  both 
eyes,  although  at  first  one  eye  may  be  more  seriously  in- 
volved than  the  other. 

The  most  important  of  those  forms  not  due  to  a  consti- 
tutional disease  is  traumatic  iridocyclitis,  because  it  is  apt 
to  be  followed  by  sympathetic  ophthalmitis  of  the  other 
eye.  Destruction  of  the  affected  eye  at  least  is  the  usual 
outcome.     Traumatic  iridocyclitis  occurs  when  a  perforat- 


184  EXTERNAL   DISEASES  OF  THE  EYE. 

ing  wound  becomes  infected;  aseptic  wounds  of  the  iris 
and  ciliary  body  heal  without  inflammation.  The  com- 
plication may  be  caused  by  operative  (as  in  cataract- 
extraction,  for  example),  as  well  as  by  accidental  injuries. 
Whenever  a  wound  penetrates  to  the  ciliary  body,  or  a 
foreign  body  is  allowed  to  remain  in  the  eye,  there  is 
danger  of  iridocyclitis  and  inflammation  of  the  other  eye. 
Sympathetic  ophthalmitis  sometimes  follows  an  acute 
purulent  iridocyclitis,  which  will  eventuate  in  panophthal- 
mitis, but  is  much  more  likely  to  develop  into  the  chronic, 
insidious  form  of  iridocyclitis,  which  at  first  does  not 
appear  to  be  at  all  alarming.  The  visual  acuity  of  the 
injured  eye  may  not  be  materially  affected,  and  no  more 
serious  symptoms  may  be  noted  than  a  slight  congestion, 
diminished  tension,  and  a  few  punctate  precipitates  on  the 
posterior  surface  of  the  cornea,  so  that  the  surgeon  hesi- 
tates to  sacrifice  the  eye.  On  the  other  hand,  if  a  phthis- 
ical bulb,  in  which  the  primary  inflammation  has  already 
subsided,  again  becomes  inflamed,  either  spontaneously  or 
äs  the  result  of  a  second  traumatism,  sympathetic  ophthal- 
mitis may  develop,  while  non-inflammatory,  painless 
atrophy  of  the  globe  is  unable  to  produce  the  condition. 
In  most  cases  the  sympathetic  inflammation  makes  its 
appearance  while  the  primary  iridocyclitis  is  still  active, 
say  from  four  to  eight  weeks  after  the  injury.  Its  coming 
is  heralded  by  prodromata  which  are  designated  sympa- 
thetic irritation,  because  they  are  not  actually  inflammatory 
in  character ;  they  are  defective  accommodation,  photo- 
phobia, and  beginning  ciliary  congestion.  These  are  soon 
followed  by  the  objective  inflammatory  symptoms,  distinct 
ciliary  congestion,  pupillary  contraction  and  synechia?, 
opacities  on  the  posterior  surface  of  the  cornea,  and  all 
the  other  signs  of  iridocyclitis.  Sympathetic  iritis  is  one 
of  the  most  malignant  forms  of  inflammation  and  often 
on  to  total  blindness.  The  route  of  transmission 
from  the  affected  to  the  unaffected  eye  has  not  as  yet  been 
discovered.  [Sympathetic  ophthalmitis  may  sometimes 
arise  in  the  wake  of  an  attack  of  sympathetic  irritation, 


DISEASES  OF  THE  IRIS  AND   CILIARY  BODY.     185 

may  sometimes  coexist  with  it,  but  frequently,  indeed 
usually,  develops  without  any  premonition  or  association 
of  this  character.  Therefore  it  would  seem  to  be  safer  to 
regard  sympathetic  irritation  and  sympathetic  inflamma- 
tion as  two  essentially  different  conditions. — Ed.] 

Diagnosis  of  Iritis. — It  is  of  vital  importance  to  be 
able  to  distinguish  iritis  and  iridocyclitis  from  glaucoma, 
because  remedies  appropriate  for  the  treatment  of  iritis 
have  the  most  disastrous  effects  in  glaucoma,  and  the  error 
might  easily  lead  to  total  blindness.  In  iritis  the  pupil 
is  contracted  ;  in  glaucoma  dilated.  The  intraocular 
tension  (which  is  markedly  elevated  in  glaucoma)  affords 
valuable  information,  and  its  investigation  must  not  be 
neglected  in  any  case  declared  to  be  iritis.  The  former 
occurrence  of  iritis  may  have  an  important  bearing  on  the 
diagnosis,  as  it  throws  light  on  the  question  of  syphilitic 
disease;  hence  a  persistent  pupillary  membrane  must  not 
be  mistaken  for  the  remains  of  synechia?.  A  persistent 
pupillary  membrane  is  not  infrequently  seen  in  the  form 
of  gray  dots  or  threads  in  the  pupillary  region,  passing 
from  the  iris  to  the  lens-capsule.  But  while  the  remains 
of  synechia:  originate  at  the  pupillary  margin  and  form  a 
wreath  or  wreath-like  patches,  the  threads  of  a  persistent 
pupillary  membrane  are  attached  to  the  small  circle  of 
the  iris  and  appear  in  the  form  of  irregular  groups. 

The  treatment  of  iritis  and  iridocyclitis  includes 
local  remedies  and  general  constitutional  medication  for 
the  removal  of  the  primary  disease.  In  every  case 
mydriasis  must  be  maintained  with  atropin  or  hyoscin, 
supplemented  with  a  few  drops  of  cocain  in  refractory 
pupils.  If  intraocular  tension  is  increased,  atropin  must 
be  withdrawn  for  a  time.  The  eye  must  be  protected 
from  light,  either  with  dark  glasses  or  by  keeping  the 
patient  in  a  dark  room,  according  to  the  severity  of  the 
iridocyclitis.  Atropin  and  dark  glasses  not  only  diminish 
the  pain  by  keeping  the  iris  quiet,  but  also  tend  to  check 
the  inflammatory  process  by  lessening  the  entrance  of 
blood  into  the  contracted  iris.     Mvdriasis  also  renders  the 


186  EXTERNAL   DISEASES  OF  THE  EYE. 

formation  of  synechia?  difficult.  In  simple  iritis,  showing 
mere  punctate  opacities,  one  to  two  drops  of  a  1  per  cent, 
solution  are  usually  sufficient  ;  in  acute  iritis  five  to  eight 
drops  per  day,  with,  if  necessary,  the  same  dose  of  a  2 
per  cent,  solution  of  cocain.  Absolute  rest  for  the  eyes 
and  abstinence  from  alcohol  in  any  form  should  be  strictly 
enforced  in  acute  iritis. 

Syphilitic  iritis  demands  vigorous  antispecific  treatment 
in  the  form  of  inunctions,  2  to  4  gm.  per  day,  and  potas- 
sium iodid,  2  to  5  gm.  per  day.  In  obstinate  cases  a 
course  of  sweating  is  recommended,  which,  with  sodium 
salicylate  internally,  is  also  applicable  to  the  rheumatic 
form. 

Tubercular  iritis  can  only  be  treated  by  general  consti- 
tutional medication  ;  excision  of  the  nodules  is  not  of 
much  avail.  On  the  other  hand,  I  have  seen  good  results 
in  several  instances  follow  the  introduction  of  sterilized 
iodoform  into  the  anterior  chamber. 

In  traumatic  iritis  prophylaxis  plays  an  important  part. 
The  strictest  asepsis  is  to  be  observed  in  all  operations 
within  the  eyeball  ;  infected  wounds  should  be  sterilized 
as  well  as  possible  with  carbolic  acid,  with  the  thermo- 
cautery, or  in  any  other  appropriate  way.  For  this  pur- 
pose iodoform  may  be  again  recommended  ;  I  once  saw, 
in  the  case  of  a  suppurating  cataract-wound,  an  apparently 
hopeless  eye  saved  by  the  introduction  of  iodoform  into 
the  wound  and  into  the  anterior  chamber.  Cold  com- 
presses, so  popular  among  the  laity,  are  to  be  absolutely 
forbidden  in  all  wounds  of  the  eyeball,  on  account  of 
their  great  liability  to  infection.  [The  Editor  has  the 
greatest  confidence  in  sterilized  ice  compresses  in  non- 
infected  wounds  of  the  eyeball.  Naturally  great  care  is 
exercised  that  the  compresses  themselves  shall  not  carry 
infection.]  If  the  wound  is  already  infected,  cold  com- 
presses, a-  well  as  leeches,  are  as  useless  as  would  be  the 
•■  singing  of  hymns  at  a  fire  "  (Hirschberg). 

Most  important  is  the  prophylaxis  of  so  dangerous  a 
disease  as  sympathetic  iritis.     Therefore,  all  injuries  likely 


DISEASES  OF  THE  IBTS  AND  CILIARY  BODY.    187 

to  produce  this  affection  must  be  treated  and  watched  with 
the  utmost  care,  and  such  eyes  must  be  enucleated  which 
threaten  sympathetic  iritis,  especially  such  as  have  badly 
healing  wounds  in  the  ciliary  region.  If  the  scars  in  such 
«yes  begin  to  contract,  they  usually  are  ready  for  enucle- 
ation, especially  if  to  other  indications  are  added  abnor- 
mally low  tension,  persistent  ciliary  congestion,  and  ten- 
derness on  pressure.  The  prevention  and  cure  of  trau- 
matic iritis  demand  the  removal  of  any  foreign  body 
which  may  be  within  the  globe,  a  procedure  still  more 
earnestly  demanded  if  sympathetic  iritis  threatens. 

If  sympathetic  inflammation  has  already  set  in,  imme- 
diate enucleation  of  the  eye  originally  affected  is  usually 
indicated.  This  is  to  be  followed  by  long-continued  myd- 
riasis (with  atropin)  in  a  dark  room  and  a  course  of  in- 
unctions with  blue  ointment. 

In  order  to  guard  against  the  occurrence  of  traumatic, 
and  especially  sympathetic  iritis,  it  is  well  never  to  oper- 
ate on  an  inflamed  eye  except  for  the  removal  of  a  for- 
eign body  or  for  other  imperative  reasons.  Operation  on  a 
sympathetically  affected  eye  is  never  advisable  until  some 
time  after  the  subsidence  of  all  inflammatory  symptoms, 
when  an  attempt  may  be  made  to  improve  the  visual  power 
by  an  iridectomy. 

If  occlusion  takes  place  after  iritis,  iridectomy  must  be 
performed  early,  to  prevent  the  occurrence  of  glaucoma. 

2.  Injuries  of  the  Iris. 

Injuries  of  medicolegal  significance,  caused  by  violent 
external  force  are  sometimes  met  with  in  the  iris.  Such 
are  fissures  in  the  pupillary  margin  and  rupture  of  the 
sphincter,  which  destroy  the  circular  outline  of  the  pupil, 
and,  by  producing  partial  or  total  paralysis,  give  rise  to 
traumatic  mydriasis,  although  the  latter  is  also  caused  by 
simple  contusion  of  the  nerves.  Iridodialysis  is  the  term 
applied  to  a  rupture  of  the  ciliary  attachment,  in  which  a 
dark  crescentic  opening  is  formed  in  the  periphery  of  the 


188  EXTERNAL   DISEASES  OF  THE  EYE. 

anterior  chamber  ;  the  pupillary  margin  at  this  point  is 
straight  instead  of  circular  and  docs  not  react.  The  iris 
may  be  completely  or  partially  detached  in  ruptures  of  the 
sclerotic  coat,  a  condition  termed  traumatic  irideremia  or 
aniridia;  or  the  iris  may  he  folded  hack  on  itself  (Plate 
34,  l>).  All  these  injuries  of  the  iris  may  he  attended 
with  hemorrhage  into  the  anterior  chamber  and  disloca- 
tion of  the  lens. 


3.  Tumors  of  the  Iris  and  Ciliary  Body. 

Cysts  usually  develop  after  perforating  wounds  of  the 
anterior  chamber.  They  are  generally  benign,  though 
somewhat  difficult  to  remove.  Operation  should  not  be 
delayed,  because  there  is  danger  of  glaucoma  and  conse- 
quent  loss  of  vision. 

Sarcoma  occasionally  occurs  in  the  iris  and  ciliary 
body.  It  is  usually  pigmented,  the  color  ranging  from 
gray  to  dark-brown  or  black,  and  very  malignant.  A 
sarcoma  sometimes  develops  from  small  pigment-spots  in 
the  iris  which  have  been  present  a  long  time  ;  the  growth 
is  at  first  very  slow,  hut  gradually  a  large  mass  is  formed 
(Plate  30,  a),  which,  if  left  to  itself,  breaks  through  the 
outer  coat.  Sarcoma  of  the  ciliary  body  may  escape  de- 
tection a  long  time,  until  finally  it  emerges  on  the  periph- 
ery of  the  anterior  chamber.  If  the  sarcoma  is  limited  to 
the  iris  and  is  very  small,  it  may  be  excised  ;  but  if  the  sar- 
coma is  large,  or  situated  in  the  ciliary  body,  enucleation 
is  necessary  to  save  the  patient's  life.  Tubercular  tumors 
have  been  referred  to  under  Iritis. 


DISEASES  OF  THE  LENS. 

The  crystalline  lens,  being  a  non-vascular  structure,  is 
not  subject  t<>  inflammation  ;  at  the  most  it  may  he  in- 
vaded secondarily  by  pus-corpuscles  after  rupture  of  the 
capsule  by  traumatism  or  suppuration. 


DISEASES   OF  THE  LENS.  189 

Cataract  is  practically  the  only  disease,  whether  pri- 
mary or  secondary  to  other  disease  or  injury  of  the  eye, 
that  occurs  in  the  lens. 

The  color  of  the  opacity  is  gray  or  bluish-white  In- 
direct light,  and  black  on  a  red  background  by  trans- 
mitted light  (Plates  32  and  33).  As  the  opacity  is  often 
situated  at  the  periphery  of  the  lens,  it  is  necessary  to 
dilate  the  pupil  to  bring  it  clearly  into  view.  If  this  is 
done  and  the  eye  is  examined  by  lateral  illumination,  the 
position  of  the  opacities  is  readily  seen.  Depending  on 
the  arrangement  of  the  lens-fibers,  an  incipient  cataract 
appears  in  the  form  of  radial  lines,  streaks,  or  wedge- 
shaped  opacities  (Plate  33,  b  and  c)  running  from  the  an- 
terior or  posterior  cortical  layer  toward  the  anterior  or 
posterior  pole,  and,  if  long  enough,  encroaching  on  the 
pupillary  region.  In  addition  a  number  of  punctate 
opacities  are  scattered  here  and  there.  The  opacities  are 
always  in  the  fibers  of  the  lens  or  in  the  epithelium  cov- 
ering the  posterior  surface  of  the  anterior  lens-capsule, 
never  in  the  capsule  itself.  When  we  speak  of  capsular 
cataraetwe  mean  opacities  due  to  proliferation  of  the  cap- 
sular epithelium,  which  are  found  exclusively  in  the  cen- 
tral portions  of  the  anterior  lens-surface,  are  sometimes 
bright  yellow,  sharply  defined,  and  in  some  cases  project- 
ing (Plate  34).  This  form  consists  of  a  dense  accumula- 
tion of  epithelial  cells,  while  the  other  varieties  of  cata- 
ract are  due  to  degenerative  changes,  being  produced  by 
the  lens-fibers  between  the  nucleus  and  the  cortex  in  the 
region  of  the  equator  separating  and  leaving  open  spaces, 
which  become  filled  with  transparent  granular  masses. 
The  fibers  in  the  equatorial  region  swell  up  and  become 
turbid,  and  eventually  break  down,  forming  a  viscid  mass 
containing  fat-granules,  droplets  of  myelin,  cholesterin- 
crystals,  and  debris.  The  distinct  swelling  which  occurs 
in  the  lens  during  the  formation  of  a  cataract  would 
appear  to  indicate  that  the  degenerative  process  is  asso- 
ciated with  an  increased  amount  of  fluid  in  the  lenticular 
substance.     The  swelling  can  be  recognized  by  the  less- 


L90  EXTERNAL    DISEASES   OF   THE  EYE. 

Plate  32. 

".  Senile  cataract,  mature — i.  e.,  the  opacity  has  extended  as  far  as 

the  capsule,  and  therefore  the  pupillary  margin.  The  patient,  a  woman 
of  72  years,  is  otherwise  in  good  health. 

h.  Traumatic  Cataract. — The  patient,  a  hoy  of  14  years,  stepped  into 
a  large  hux  with  one  foot  and  struck  his  left  eye  against  the  edge.  The 
eye  was  probably  injured  by  a  nail  or  a  sharp  splinter,  for  we  see  in  the 
lower  portion  of  the  cornea  (a  little  to  the  nasal  side  of  the  center)  a 
freshly  healed  wound  about  2  mm.  long,  appearing  as  a  grayish  streak, 
with  a  corresponding  wound  in  the  nasal  half  of  the  iris  and  in  the  an- 
terior lens-capsule.  The  opacity  has  spread  from  the  anterior  cortex, 
where  it  surrounds  the  wound  in  the  capsule,  to  the  posterior  cortex, 
forming  a  delicate  rosette,  which  is  only  seen  by  transmitted  light. 
There  is  some  ciliary  injection.  Visual  acuity,  -fa.  Two  weeks  later  the 
opacity  in  the  posterior  cortex  had  diminished,  while  that  in  the  anterior 
was  more  pronounced,  and  the  lens  began  to  swell.  In  the  course  of  the 
next  two  weeks  the  entire  lens  became  opaque.  The  unabsorbed  portion 
of  the  cataract  was  then  removed  by  repeated  discission,  and  after  a  few 
months  the  visual  acuity  was  found  to  be  g.  with  a  hypermetropia  of 
12  D. 

ened  depth  of  the  anterior  chamber  from  forward  disloca- 
tion of  the  iris.  The  entrance  of  aqueous  humor  into 
the  lens  from  any  cause,  such  as  injury  to  the  anterior 
capsule,  is  followed  by  swelling  and  turbidity  of  the  lens, 
and  what  is  known  as  traumatic  cataract  (Plate  32,  b). 

Subjective  symptoms — that  is  to  say,  impairment  of 
vision — are  present  only  when  the  cataract  affects  the 
axis  of  the  lens ;  a  peripheral  opacity  may  be  present  a 
long  time  without  being  discovered.  A  central  cataract 
soon  betrays  itself  by  the  appearance  of  dark  spots  and 
streak-.  "  muscae,"  in  the  field  of  vision,  and  by  diplopia, 
which  is  particularly  noticeable  when  the  patient  looks  at 
a  light.  Jf  the  entire  surface  of  the  lens  becomes  turbid, 
the  visual  deterioration  is.  of  course,  greater  than  it  is  when 
a  lew  rays  of  light  can  still  lind  their  way  through  streaks 
of  opacity.  As  the  cataract  progresses  the  visual  acuity  de- 
creases more  and  more,  although  in  an  otherwise  healthy 
eye  some  degree  of  vision  i-  always  preserved  in  simple 
cataract,  enabling  the  patient  to  discern  movements  of  the 
hand   at  20  to  30  cm.  and  to  locate  a   candle   in   the  dark 


Tab    32. 


Lit h.  Amt  F.  Reiditwld,  München. 


DISEASES  OF  THE  LENS.  191 

correctly  in  any  direction  (see  p.  43).  The  flame  of  a 
candle  can  always  be  seen  in  a  dark  room  at  a  distance  of 
3  meters  at  least.  If  even  this  power  is  lost,  we  must 
assume  the  existence  of  morbid  changes  in  the  deeper 
coats  of  the  eye,  retinal  detachments,  atrophy  of  the  optic 
nerve,  diffuse  choroiditis,  etc.  Sometimes  the  beginning 
of  senile  cataract  can  be  inferred  from  the  development 
of  myopia  or  from  the  increase  in  an  already  existing 
myopia,  due  to  the  fact  that  the  swelling  of  the  lens  in- 
creases its  refractive  power.  The  various  forms  of  cata- 
ract are  classified  clinically  as  follows  : 


a.  Partial   Stationary  Cataract. 

Under  this  head  are  included  : 

i.  Anterior  Polar  Cataract. — A  small  white  spot 
or  pyramidal  mass  is  formed  at  the  anterior  pole  of  the 
lens,  and  sometimes  drawn  out  to  a  point  (Plate  34, a). 
It  is  a  so-called  capsular  cataract — i.  c,  the  opacity  con- 
sists of  proliferating  capsular  epithelium.  It  may  be 
congenital,  and  is  in  that  case  usually  bilateral ;  or  it  may 
be  acquired.  A  central  corneal  ulcer  perforates,  the 
aqueous  humor  escapes,  and  the  lens  is  brought  against 
the  site  of  the  ulcer,  exciting  proliferation  of  the  capsular 
epithelium.  Hence  a  macule  is  always  seen  in  the  center 
of  the  cornea  in  such  cases.  The  process  just  described 
occurs  only  in  childhood,  usually  after  gonorrheal  conjunc- 
tivitis. An  anterior  polar  cataract  is  always  behind  the 
lens-capsule,  and  cannot  therefore  be  detached  from  the 
lens  without  opening  the  capsule  and  producing  traumatic 
cataract.  If  the  opacity  is  small,  the  visual  disturbance  is 
slight,  but  increases  in  a  strong  light  with  the  contraction 
of  the  pupil. 

2.  Posterior  polar  cataract  forms  an  opacity  on 
the  posterior  pole,  and  may  be  congenital  (rarely),  when 
it  is  caused  by  remains  of  the  fetal  tunica  vasculosa  lentis 
and  of  the  hyaloid  artery ;  or  acquired,  after  pigmentary 
degeneration  of  the  retina,  choroiditis,  or  degeneration  of 


192  EXTERNAL    DISEASES   OF   THE   EYE. 

Plate  33- 

a.  Zonular  Cataract. — The  patient  is  7  years  old,  and  has  had  lamellar 
cataract  in  both  eyes  since  infancy.  His  visual  acuity,  which  was  never 
quite  normal,  is  now  I  in  the  eye  represented  in  the  plate,  the  defect 
becoming  more  noticeable  on  his  being  sent  to  school.  The  lens  was 
removed,  as  the  eyes  are  in  other  respects  normal. 

b.  The  same  eye  by  transmitted  light.  The  pupil  is  dilated,  showing 
fine,  radiating  lines  surrounding  the  central  opacity  (an  unusual  con- 
dition). 

c.  Incipient  senile  cataract  in  transmitted  light,  showing  the  radiating 
streaks  of  opacity  to  the  best  advantage,  after  dilatation  of  the  pupil. 
In  other  respects  the  eye  is  normal.  The  slight  degree  of  ciliary  con- 
gestion is  caused  by  a  trifling  abrasion  of  the  cornea,  not  shown  in  the 
picture. 


the  vitreous.  The  last  two  diseases  usually  produce  some- 
what greater  opacity  on  the  posterior  cortex,  and,  with  the 
exception  of  the  congenital  form,  this  posterior  cataract 
shows  a  tendency  to  progress.  The  opacity  caused  by 
pigmentary  degeneration,  ou  the  other  hand,  remains  sta- 
tionary for  a  long  time.  It  can  be  detected  only  with 
the  ophthalmoscope  by  transmitted  light,  and  is  one  of 
the  signs  of  this  retinal  disease. 

3.  Perinuclear,  zonular,  or  lamellar  cataract, 
i-  the  most  frequent  form  of  cataract  in  childhood,  and 
is  supposed  to  have  something  to  do  with  rhachitis 
(  Horner).  It  consists  of  two  cup-shaped  opacities,  enclos- 
ing the  transparent  nucleus  between  them.  The  size  of 
the  nucleus  and  of  the  cataract  varies  ;  the  one  shown  in 
Plate  33,  ",  for  example,  is  quite  small.  It  is  usually 
larger,  and  appears  by  lateral  or  transmitted  light  like  a 
round  disk,  which  by  lateral  illumination  shows  a  distinct 
convexity;  and  if  the  light  (in  lateral  illumination)  is 
thrown  on  the  posterior  half  of  the  lens  the  po>teri<>r 
opacity  is  seen  with  its  concavity  directed  forward.  Some- 
times the  margin  of  a  lamellar  cataract  is  seen  by  trans- 
mitted light  to  he  covered  with  small  projections,  cor- 
responding tu  -lender  strips  of  opacity  placed  on  the  vd^r 
of  the  cataract,  and   therefore  called   "riders."      Jn  other 


Tab.  33. 


LtÜt.Anst  /■:  fh'uiihoht.  München. 


DISEASES  OF  THE  LENS.  193 

cases  short  streaks  are  seen  nearer  the  periphery  (Plate 
33,6).  Occasionally  we  meet  with  a  case  in  which  the 
lamellar  cataract  remains  rudimentary  and  the  disks  are 
represented  by  fine  disseminated  dots.  The  visual  dis- 
turbance is,  of  course,  correspondingly  slight,  while  in 
severe  cases  it  is  extreme,  especially  when  the  pupil  is 
contracted,  not  a  ray  of  light  being  able  to  get  past  the 
cataract  and  reach  the  retina.  Lamellar  cataract  is  usually 
bilateral  and  stationary,  but  later  in  life  may  become 
complete. 

In  the  treatment  of  the  first-named  varieties  of  cata- 
ract operative  interference  is  indicated  only  when  the  cata- 
ract is  extensive ;  lamellar  cataract,  however,  usually 
requires  operative  removal  sooner  or  later.  Simple  iridec- 
tomy (at  the  lower,  inner  angle)  may  allow  some  light  to 
enter  past  the  cataract  in  mild  cases  ;  but,  as  a  rule,  removal 
of  the  lens  by  discission  is  indicated. 

b.  Progressive  Cataracts. 

This  group  comprises  the  more  frequent  forms  of  cata- 
ract, the  most  important  of  which  is 

I.  Senile  Cataract. — It  begins  as  a  spoke-like  ar- 
rangement of  lines,  streaks,  or  wedges,  radiating  from  the 
pole  of  the  lens,  incipient  cataract,  goes  on  developing  as 
Cataracta  intumescens,  and  becomes  complete,  Cataracta 
matura,  when  the  opacity  reaches  the  capsule,  so  that  the 
iris  does  not  throw  a  shadow  on  the  opacity  by  lateral 
illumination  (Plate  32,  a).  The  cataract  is  called  "ripe" 
at  this  stage,  because  it  is  in  the  best  condition  for  opera- 
tive removal,  the  soft  consistency  of  the  cortex  permitting 
its  complete  separation  from  the  capsule.  In  a  strong 
light  the  yellowish  nucleus  may  be  seen  shining  through 
the  grayish  cortical  layers.  The  nucleus  may  be  colorless. 
Senile  cataract  is  caused  by  the  physiologic  sclerosis  of  the 
lens  due  to  age,  which  is  the  cause  of  diminished  accom- 
modation (see  p.  53)  and  serves  to  protect  the  nucleus  from 
cataractous  change,  as  shown  by  the  fact  that  it  retains  its 

13 


194  EXTERNAL   DISEASES  OF  THE  EYE. 

Plate  34. 

a.  Anterior  polar  cataract,  so-called  pyramidal  cataract.  The  boy, 
who  is  15  years  old,  did  not  have  any  purulent  discharge  at  birth;  but 
six  months  later  he  was  seized  with  convulsions.  The  physician  who 
was  called  at  the  time  discovered  a  spot  in  the  eye.  Hereditary  syphilis 
is  suspected,  as  there  were  two  premature  births  in  the  family  and  eight 
children  died  at  ages  ranging  from  eight  to  ten  weeks.  There  are  only 
three  children  living.  No  other  si.uns  of  syphilis  are  to  be  found  ;  the 
cornea  is  perfectly  transparent  and  the  fundus  of  both  eyes  normal. 
Visual  acuity  on  both  sides  is  only  \,  as  the  centrally  situated  opacity, 
of  course,  produces  marked  disturbance,  especially  with  contracted 
pupil.  On  both  sides  a  small  pointed  cone  is  seen  on  a  r'ound,  grayish- 
white  base  2.5  mm.  in  diameter,  projecting  into  the  anterior  chamber.  The 
remaining  portions  of  the  lens  are  clear.  In  performing  discission  a  cir- 
cular section  was  made  around  the  polar  opacity  and  the  latter  extracted. 
Microscopic  examination  shows  it  to  be  a  so-called  capsular  cataract, 
situated  under  the  capsule.  The  operative  removal  of  the  lens  was 
successful,  and  resulted  in  a  visual  acuity  on  both  sides  of  i,  with  hyper- 
metropia  of  13  D. 

b.  Subconjunctival  Displacement  of  the  Lens.— Three  months  and  a 
half  ago  the  patient,  a  man  of  56  years,  struck  his  eye  against  the  limb 
of  a  tree.  The  accident  was  immediately  followed  by  marked  reduction 
of  visual  acuity  ;  at  present  the  patient  is  just  able  to  count  fingers  at 
2-V  meters.  Convex  glasses  have  no  effect  ;  the  left  eye  is  normal.  The 
scar  in  the  sclera,  through  which  the  lens  escaped,  is  plainly  seen  on  the 
temporal  side  of  the  cornea.  The  pupil  is  displaced  outward,  having 
evidently  been  turned  backward  by  the  force  of  the  blow.  Streaks  of 
injected  vitreous  are  seen  running  toward  the  seat  of  rupture.  The 
posterior  layers  are  so  turbid  with  blood  that  the  fundus  is  barely  vis- 
ible ;  but  a  rent  in  the  choroid  coat  can  be  seen  on  the  temporal  side. 
The  conjunctiva  was  divided  and  the  lens,  which  had  become  adherent 
and  annoyed  the  patient,  removed  without  injury  to  the  original  rupture 
or  escape  of  the  vitreous.     Complete  cure  in  ten  days. 

transparency  more  or  loss  perfectly  within  the  turbid 
cortex.  After  the  seventieth  year  the  sclerosis  extends 
almost  to  the  capsule,  the  usual  gray  color  of  the  opacity 
is  wanting,  and  it  may  happen  that  the  lens  remains  semi- 
transparent,  with  a  dark  reflex  due  to  the  absence  of  corti- 
cal substance  and  the  yellowish-brown  discoloration  of 
the  nucleus — <-at<ii-<tct<t   nigra. 

The  stage  of  maturity  is  followed  by  that  of  "  over- 
ripeness,"  during  which  the  volume  of  the  lens  gradually 


Tab.  34 


® 


^ 


v-v 


LiJfi.  Anst  /■:  Reichhold,  München . 


DISEASES  OF  THE  LENS.  195 

diminishes,  the  anterior  chamber  becomes  abnormally 
deep,  and  an  anterior  capsular  cataract  not  infrequently 
appears  in  the  shape  of  small  white  dots.  Shining  choles- 
terin-crystals  are  seen  suspended  in  the  liquefied  cataract. 
As  the  cataract  continues  to  shrink,  it  becomes  tremulous, 
and,  finally,  the  zonula  may  give  way  and  produce  luxa- 
tion of  the  cataract. 

2.  Congenital  cataract  is  much  less  frequent  than 
the  senile  form  ;  it  is  usually  bilateral  and  soft,  as  there  is 
no  nucleus.  In  very  exceptional  cases  congenital  total 
cataract  is  hard,  for  reasons  that  are  not  understood  as  yet. 

3.  Traumatic  Cataract.— This  is  nearly  always 
progressive.  Any  laceration  of  the  lens-capsule,  which 
admits  the  aqueous  humor  or  vitreous  body  to  the  sub- 
stance of  the  lens,  is  followed  by  cataract.  The  injury 
may  be  direct,  caused  by  some  perforating  instrument 
(knife,  scissors,  foreign  body,  etc.) ;  or  indirect,  from  con- 
tusion of  the  entire  globe,  the  capsule  probably  becoming 
ruptured  at  the  equator.  In  rare  instances  cataract  may 
be  produced  by  mere  concussion  of  the  lens  without  solu- 
tion of  continuity  in  the  capsular  structures.  In  large 
wounds  of  the  anterior  capsule  the  greater  part  of  the  lens 
may  become  turbid  within  twenty-four  hours  ;  in  smaller 
wounds  the  cataract  develops  more  gradually.  A  grayish 
or  bluish-white  discoloration  at  first  appears  about  the  in- 
jured spot  (Plate  32,  b) ;  the  lens-substance  swells  and 
projects  into  the  anterior  chamber  in  the  form  of  a  cone. 
Particles  of  the  lens-substance  separate  and  sink  to  the 
bottom.  In  small  wounds  the  swelling  is  inconsiderable, 
and  absorption  of  the  cataract  in  the  anterior  chamber, 
which  is  usually  quite  rapid  in  young  people,  takes  place 
more  slowly  in  consequence.  If  the  communication  be- 
tween the  aqueous  humor  and  the  lens  is  maintained, 
swelling  and  absorption  continue  until  all  of  the  lens-sub- 
stance except  the  capsule  is  removed.  A  small  rent  in  the 
capsule  may  be  enlarged  by  the  swelling  of  the  cataract; 
or,  if  it  is  very  small,  it  may  be  closed,  either  by  the  pro- 
liferation of  capsular  epithelium  or  by  adhesion  of  the  iris. 


196  EXTERNAL   DISEASES  OF  THE  EYE. 

Such  minute  lacerations  often  produce  a  delicate  rosette- 
like opacity  (seen  by  transmitted  light)  in  the  posterior 
cortex  of  the  lens,  and  the  cataract  may  remain  stationary 
for  a  time,  or  even  diminish  ;  but,  as  a  rule,  it  becomes 
progressive  and  goes  on  to  total  opacity. 

Secondary  <jl<titc<>in<t  is  an  important  complication  of 
traumatic  cataract.  As  soon  as  the  swelling  of  the  lens 
becomes  excessive  there  i-  danger  of  glaucoma,  especially 
in  old  people.  The  increase  in  tension  is  at  once  indi- 
cated by  cloudiness  of  the  cornea,  and,  unless  the  pressure 
is  relieved  by  paracentesis  cornea?  and  evacuation  of  the 
cataractous  mass,  vision  is  gradually  destroyed. 

Cataract  is  sometimes  attended  with  inflammation,  the 
anterior  chamber  becoming  contaminated  at  the  time  of 
the  injury  and  setting  up  an  iritis  or  iridocyclitis.  Ad- 
hesions are  formed  between  the  lens  and  the  iris  or  ciliary 
body,  giving  rise  to  Cataracta  accreta,  which  does  not  lend 
itself  readily  to  operation. 

4.  Complicated  cataract  occurs  in  consequence  of 
other  diseases  of  the  eye,  such  as  acute  iritis  and  irido- 
cyclitis, especially  the  purulent  forms  (creeping  ulcer)  ; 
chronic  iridochoroiditis  with  opacities  in  the  vitreous, 
separation  and  pigmentary  degeneration  of  the  retina,  and 
the  end-stage  of  glaucoma.  Persons  with  a  high  degree 
of  myopia  show  a  certain  tendency  to  cataract,  especially 
in  advanced  life.  Complicated  cataract  is  recognized  by 
its  abnormal,  dirty-yellow  or,  if  calcification  has  taken 
place,  chalky  color,  by  adherence  of  the  iris,  by  thickening 
of  the  capsule,  tremulousness,  etc.,  and  especially  by  the 
loss  of  function.  In  normal  cataract,  as  has  been  stated 
(see  p.  57),  the  power  of  locating  a  candle  in  the  dark  is 
always  retained. 

In  addition  to  the  causes  of  cataract  which  have  been 
mentioned  (senility,  traumatism,  etc.1.  we  recognize  dia- 
betes and  albuminuria  and   hereditary  disposition. 

In  the  diagnosis  the  following  points  are  to  be  borne 
in  mind  :  Incipient  cataract  must  never  be  diagnosed 
until  the   eye  has  been   examined   by   transmitted   light. 


DISEASES  OE  THE  LENS.  197 

The  sclerosis  incident  to  old  age  often  produces  an  intense 
gray  reflex  in  the  pupil,  which  may  be  mistaken  for  a 
cataractous  lens.  By  transmitted  light,  however,  the 
pupil  exhibits  a  beautiful  red  reflex,  and  the  streaks  of 
opacity  which  characterize  incipient  cataract  are  absent 
(Plate  33,  c).  In  traumatic  cataract,  if  the  lens  becomes 
opaque  rapidly,  a  bright  metallic  reflex  is  sometimes  seen 
in  the  posterior  layers  by  lateral  illumination;  and  must 
not  be  mistaken  for  a  foreign  body.  The  latter  appears 
black  by  transmitted  light,  which  is  not  the  case  with  the 
reflex  referred  to. 

The  treatment  of  all  forms  of  cataract,  except  the 
complicated,  is  essentially  surgical.  Partial  juvenile  cat- 
aracts are  treated  by  discission,  and  the  semifluid  mass  is 
evacuated  through  an  incision  in  the  cornea.  Complete 
soft  cataracts  can  also  be  removed  by  means  of  a  short 
incision  through  the  cornea  and  capsule.  To  remove  a 
senile  nuclear  cataract  a  semicircular  incision  must  be 
made  concentric  with  the  corneal  margin  and  involving 
more  than  one-third  of  the  circumference.  If,  after  the 
delivery  of  the  cataract  through  the  pupil  and  corneal 
wound,  it  is  found  difficult  to  replace  the  iris,  a  small 
section  must  be  removed  by  means  of  iridectomy.  It  is 
sometimes  advisable  in  slowly  ripening  cataracts  to  operate 
before  the  stage  of  maturity  has  been  reached.  In  such 
cases  iridectomy  is  performed  before  the  cataract  is  deliv- 
ered, in  order  to  make  more  room  for  the  egress  of  the 
lens-substance  and  prevent  an  increase  in  tension  from 
swelling  of  the  cortical  remains. 

In  traumatic  cataract  the  intraocular  tension  must  be 
carefully  watched  and  a  part  of  the  lens-substance  re- 
moved by  paracentesis  of  the  cornea,  if  the  pressure  rises. 
If  the  swelling  is  great,  the  pupil  must  be  well  dilated  to 
allow  the  cataractous  mass  free  access  to  the  anterior  chamber. 

Dislocation  of  the  Lens. 

This  is  due  to  anomalies  in  the  zonula.  Owing  to  con- 
genital unequal  development,  deceleration  of  the  lens  to- 


198  EXTERNAL  DISEASES  OF  THE  EYE. 

ward  the  shorter  zonula  takes  place  :  Ectopia  lentis  congenita. 
If  the  upper  zonula  is  shorter  than  the  lower,  the  lens  is 
displaced  upward  and  the  dislocation  increases  as  the 
lower  zonula  gradually  atrophies  and  disappears.  Such  a 
dislocation  upward  results  in  diminution  of  the  upper 
angle  of  the  anterior  chamber  and  tremulousness  of  the 
iris,  which  loses  the  support  of  the  lens.  The  same  phe- 
nomena are  observed  alter  rupture  of  the  zonula  by  a  blow 
on  the  eye,  a  not  infrequent  accident.  The  lens  may 
suffer  only  partial  dislocation  to  one  side,  so  that  the 
margin  is  >(jen  as  a  sharp  circular  line  within  the  pupil 
(subluxatio  lentis),  or  it  may  be  thrown  into  the  vitreous 
body  (luxatio  lentis).  In  the  latter  case  the  normal  gray 
color  of  the  pupillary  reflex  is  changed  to  black,  the  entire 
iris  is  tremulous,  and  the  lens  is  seen,  by  lateral  illumina- 
tion or  with  the  ophthalmoscope,  as  a  spherical  body  freely 
movable  within  the  vitreous.  In  favorable  cases  it  becomes 
fixed  after  a  time  by  adhesions,  cataract  develops,  and  the 
lens  contracts ;  usually,  however,  a  movable  lens  gives 
rise  to  glaucoma,  probably  by  irritating  the  ciliary  proc- 
esses which  secrete  the  aqueous  humor.  Even  subluxa- 
tion may  have  this  effect. 

A  partial  dislocation,  whether  congenital  or  traumatic, 
is  very  apt  to  become  complete.  Complete  luxation  may 
be  anterior  (although  rarely),  and  a  shrunken  and  turbid, 
or  a  -emitransparent,  lens  is  sometimes  found  in  the  ante- 
rior chamber.  If  the  lens  is  transparent,  the  yellowish 
luster  of  its  margin  gives  the  impression  of  a  large  drop 
of  oil  in  the  anterior  chamber.  In  violent  contusions 
with  rupture  of  the  sclera  the  lens  is  sometimes  bodily 
ejected  from  the  eye,  and  the  same  accident  may  occur  in 
perforation  of  the  cornea  by  extensive  ulcerations  if  the 
patient  strains  during  the  examination. 

Spontaneous  luxation  into  the  vitreous  chamber  is 
caused  by  atrophy  of  the  zonula  in  consequence  of  lique- 
faction of  the  vitreous  humor  occurring  in  severe  myopia, 
anterior  choroiditis,  or  retinal  separation.  Atrophy  of 
the  zonula  sometimes  occurs  through  the  shrinking  of  an 


DISEASES  OF  THE   VITREOUS  BODY.  199 

over-ripe  cataract,  and  luxation  may  be  induced  by  the 
slightest  shock,  a  blow,  or  the  momentary  congestion 
caused  by  bending  over  or  sneezing. 

The  greater  the  dislocation  of  the  lens,  the  greater 
the  visual  disturbance.  Subluxation  gives  rise  to  myopia 
and  astigmatism,  and,  later,  to  more  marked  disturbances 
from  obscuration  of  the  lens.  Complete  dislocation  of 
the  lens  from  the  pupillary  area  has  the  same  effect  on 
vision  as  absence  of  the  lens,  or  aphakia,  and  causes  a  re- 
duction in  the  refractive  power,  which  in  emmetropic  eyes 
amounts  to  10  D.  If  the  lens  becomes  fixed  in  the  vitre- 
ous body  and  causes  no  further  disturbance,  the-  patient 
can  see  quite  well  with  cataract-glasses.  Such  cases  are, 
however,  exceptional.  Usually  the  condition  is  very  pain- 
ful and  gradually  leads  to  glaucoma  and  total  blindness. 

The  prognosis  in  dislocation  of  the  lens  is  very  grave. 
The  eye  is  always  in  great  danger  and  in  many  cases  its 
loss  is  unavoidable. 

Treatment. — In  a  very  few  cases  the  aphakia  may  be 
corrected  by  the  use  of  suitable  convex  glasses.  In  par- 
tial dislocations,  especially  in  young  persons,  the  lens 
should  be  removed  by  discission ;  in  fresh  luxations  into 
the  vitreous  chamber  an  attempt  may  be  made  to  induce 
fixation  by  rest  in  bed,  any  intercurrent  rise  in  tension  to 
be  met  by  the  instillation  of  myotics  (physostigmin,  pilo- 
carpin),  or  the  glaucoma  may  be  checked  by  repeated 
sclerotomy.  Extraction  of  the  lens  is  usually  attended 
with  a  dangerous  escape  of  vitreous  humor.  Glaucoma 
not  infrequently  necessitates  removal  of  the  globe. 


DISEASES   OF   THE   VITREOUS   BODY. 

Disease  of  the  vitreous,  in  the  large  majority  of  cases, 
is  secondary  to  inflammation  of  the  ciliary  body,  choroid, 
and  retina,  and  manifests  itself  in  turbidity,  due  to  the 
entrance  of  inflammatory  material,  and   in  degeneration, 


200  EXTERNAL   DISEASES  OF  THE:  EYE. 

Plate  35- 

a.  Suppuration  in  the  Vitreous,  Caused  by  a  Piece  of  Iron.— B.  H., 
aged  !i  years,  while  digging  with  a  small  hoe  on  April  17.  1897,  suddenly 
felt  something  enter  her  left  eye.  On  April  20  she  was  admitted  to  the 
clinic,  the  eye  having  meanwhile  become  inflamed  and  vision  impaired. 
The  cornea  was  covered  with  a  diffuse  haze,  and  by  lateral  illumination  a 
tine  gray  scar,  about  1.5  mm.  in  length,  was  seen  in  the  inner  upper  quad- 
rant where  the  substance  had  entered  the  eye.  There  was  a  broad  adhe- 
sion between  the  lens  and  the  iris.  Hypopyon  of  2  mm.  in  the  anterior 
chamber;  large  exudate  in  the  pupil,  making  it  difficult  to  determine 
the  condition  of  the  lens.  It  was  found  impossible  to  extract  the  piece 
of  iron  with  the  large  electromagnet.  Six  days  later  (when  the  picture 
was  taken)  the  edema  and  redness  of  the  conjunctiva  had  subsided,  the 
anterior  chamber  was  clear,  and  the  pupillary  exudate  had  shrunk  to  a 
mere  shred.  The  lens  was  not  distinctly  cataractous.  but  displayed  a 
greenish-yellow  reflex,  indicating  suppuration  in  the  vitreous.  Visual 
acuity  reduced  to  light-perception  at  20  cm.  On  May  12  enucleation  was 
performed.  The  piece  of  iron  was  found  embedded  iu  the  nasal  portion 
of  the  vitreous,  surrounded  by  pus.     Normal  recovery. 

!>.  Panophthalmitis  from  the  Entrance  of  a  Piece  of  Iron  into  the 
Vitreous.— B.  M.,  a  peasant-woman.  41  years  old,  got  something  in  her 
right  eye  while  hoeing  potatoes.  At  first  she  felt  only  a  sensation  of 
grittiness:  but  vision  at  once  became  dim,  and  during  the  night  she 
had  violent  pains  in  the  eye  and  on  the  right  side  of  the  brow.  The 
next  day  the  lids  were  swollen  and  somewhat  inflamed,  the  eyeball  pro- 
truding and  less  movable  than  normal,  and  moderate  Chemosis  developed. 
No  dacryostenosis  or  conjunctivitis.  Cornea  uniformly  opaque,  with 
a  sharp  linear  wound,  1.5  mm.  iu  length,  in  the  outer  upper  quad- 
rant. The  iris  was  barely  visible.  Small  hypopyon  and  exudate  in 
the  pupil.  No  reflex  could  be  observed.  When  the  eye  was 
brought  near  the  large  electromagnet,  the  piece  of  iron  at  once 
emerged  through  the  opening.  The  panophthalmitis,  however,  contin- 
ued and  the  condition  seen  in  the  picture  developed  :  Marked  exoph- 
thalmos, edema  of  the  conjunctiva  (chemosis),  and  grayish-green  discol- 
oration of  the  cornea.  A  shred  of  necrotic  tissue  adheres  to  the  wound, 
evidently  a  portion  of  vitreous  which  has  undergone  liquefaction- 
necrosis  and  escaped  through  the  wound,  as  it  is  found  impossible  to 
wipe  it  off.  Enucleation  was  performed  twelve  days  after  the  accident, 
complete  panophthalmitis  having  developed.  The  glohe  was  filled  with 
a  yellowish-brown  lardaeeous  mass,  from  which  three  colonies  of  strep- 
tococci and  one  colony  of  multiarticular,  vacuolated  bacilli,  resembling 
the  "  Wurzell  bacillus,"  were  obtained.  The  wound  healed  without  fur- 
ther complications. 


Tab.  35. 


1  I  v\  \ 


l.ith.  Ans/  F.  Retchhold,  München . 


DISEASES  OF  THE   VITREOUS  BODY.  201 

leading  to  liquefaction  or  to  the  formation  of  fibrillar, 
flake-like  opacities.  As  the  vitreous  possesses  a  feebler 
regenerative  power  than  any  other  tissue  in  the  body,  the 
slightest  escape  of  vitreous  humor  through  a  traumatic  or 
operative  wound,  or  any  interference  with  its  structure  by 
the  introduction  of  instruments,  is  likely  to  produce  opacity 
and  separation  of  the  retina. 

The  suppuration  caused  by  the  entrance  of  a  foreign 
body  deserves  special  mention.  What  has  been  said  in 
this  connection  about  injuries  of  the  sclera  may  be  sup- 
plemented by  the  following  :  A  foreign  body  which  pene- 
trates as  far  as  the  vitreous  and  retina  is  more  likely  to 
enter  through  the  cornea  than  through  the  sclera ;  it  may 
pass  through  the  iris  and  the  lens  (Plate  36,  6),  or  through 
the  lens  only,  and  sink  to  the  bottom  or  continue  its  flight 
to  the  retina,  depending  upon  the  amount  of  momentum 
it  has  acquired.  Having  reached  the  retina  the  intruder 
either  buries  itself  in  its  tissues  or  recoils  and  lodges  some- 
where in  the  lower  anterior  part  of  the  vitreous,  where  it 
cannot  well  be  detected  even  with  the  ophthalmoscope,  so 
that  its  presence  has  to  be  inferred  from  the  lesion  in  the 
retina. 

If  traumatic  cataract  develops,  detection  is  even  more 
difficult,  although  its  probable  course  can  be  approximately 
determined  by  the  position  of  the  wound  in  the  cornea, 
iris,  and  lens.  [The  Röntgen  rays  may  always  be  utilized 
to  locate  foreign  bodies  within  the  eyeball. — Ed.]  If  the 
wound  remains  aseptic,  the  piece  of  iron  can  usually  be 
extracted  by  means  of  the  large  electromagnet  (see  p.  175), 
which  may  also  be  utilized  to  determine  the  nature  of  the 
foreign  body.  Unfortunately,  however,  such  particles  of 
iron  usually  set  up  a  violent  suppurative  inflammation, 
which  results  either  in  suppuration  of  the  vitreous  (Plate 
35,  a)  or  in  panophthalmitis  (Plate  35,  b).  This  is  par- 
ticularly the  case  when  the  particle  of  iron  is  derived 
from  a  hoe  or  similar  digging  tool.  Panophthalmitis 
may  declare  itself  within  forty-eight  hours.  The  infec- 
tion is  probably   carried   by  the   substance  itself,   since 


202  EXTERNAL  DISEASES   OF  THE   EYE. 

a  piece  of  a  hoe,  which  is  contaminated  with  dirt,  is  more 
likely  to  produce  a  severe  purulent  inflammation  than  a 
spicule  of  forged  iron,  a  glass  splinter,  grain  of  powder, 
or  other  foreign  body.  It  may  be  that  in  some  cases  in- 
fection occurs  secondarily  through  the  wound. 

Occasionally  the  entrance  of  a  foreign  body  into  the 
vitreous  chamber  gives  rise  to  an  insidious  attack  of  irido- 
cyclitis, which  is  no  less  dangerous  to  the  life  of  the 
eye  than  an  acute,  purulent  inflammation.  Enucleation 
is  usually  necessary  to  save  the  other  eye,  for  sympathetic 
ophthalmitis  is  particularly  apt  to  develop  in  such  cases. 
Even  if  no  inflammatory  process  of  any  kind  develops 
after  the  entrance  of  a  spicule  of  iron,  the  eyesight  may 
eventually  be  destroyed  by  siderosis — i.  c,  gradual  chem- 
ical solution  of  the  iron  which  is  deposited  on  the  retina. 
In  a  few  rare  instances  the  presence  of  iron-particles  has 
been  tolerated  without  detriment  to  the  eye.  Aseptic 
particles  of  copper  are  at  first  tolerated,  but  eventually 
injure  the  retina  ;  although,  if  they  become  encapsuled  in 
the  anterior  portion  of  the  vitreous,  a  serviceable  degree 
of  visual  acuity  may  be  retained  for  some  time. 

Enucleation  is  indicated  in  most  cases  of  suppuration 
in  the  vitreous  and  of  panophthalmitis.  The  latter  is  recog- 
nized by  edema  of  the  lids,  the  conjunctiva,  Tenon's  space, 
and  the  adjacent  orbital  tissue,  which  produces  exophthal- 
mos. The  inflammatory  edema  in  the  orbit  is  caused  by 
the  toxins  elaborated  by  the  pyogenic  microorganisms  in 
tin  interior  of  the  bulb,  and  not  by  the  microbes  them- 
selves, since  they  cannot  well  penetrate  beyond  the  bulb. 
For  this  reason  enucleation  may  be  performed  during  the 
height  of  the  panophthalmitis  without  danger  of  the  in- 
flammation spreading  downward  and  to  the  brain,  provid- 
ing the  eyeball  does  not  become  infected  during  the  opera- 
tion by  soiled  fingers  or  instruments. 

In  these  cases  of  injury  to  the  eye  by  a  particle  of  iron, 
sustained  while  the  patient  is  hoeing  in  the  fields  or  doing 
any  work  in  which  iron  is  made  to  strike  iron,  as  in  cutting 
with  a  chisel,  for  example,  the  surgeon  should  not  allow 


GLAUCOMA.  203 

himself  to  be  influenced  by  the  statement  that  the  sub- 
stance merely  hit  the  eye  without  entering.  It  is  quite 
common  to  be  told  by  the  patient  that  he  saw  a  stone  as 
big  as  his  fist  strike  him  on  the  eye  and  fly  off,  and  then 
to  find  a  piece  of  iron  in  the  depths  of  the  eyeball.  The 
illusion  may  be  explained  by  the  fact  that  the  patient  sees 
the  foreign  body  entoptrically  magnified  during  its  pas- 
sage through  the  vitreous,  and  projects  its  flight  outward. 
In  all  such  cases,  therefore,  it  is  of  the  utmost  impor- 
tance to  make  a  thorough  search  for  particles  of  iron,  and 
to  remove  the  intruder  as  quickly  as  possible.  By  prompt 
removal  the  eye  may  be  saved  even  when  the  particle  of  iron 
is  from  a  hoe ;  but  every  minute  of  delay  makes  the  prog- 
nosis more  doubtful.  The  best  method  to  pursue  is  the 
one  described  on  p.  175. 


GLAUCOMA. 


Increased  intraocular  tension,  increased  hardness  of  the 
eyeball,  or  glaucoma,  is  one  of  the  most  important  dis- 
eases of  the  eye,  and  every  practising  physician  should 
be  perfectly  familiar  with  its  symptoms,  as  the  integrity 
of  the  affected  eye  depends  on  prompt' application  of  the 
proper  treatment 

There  are  two  varieties  :  primary  and  secondary  glau- 
coma. 

i.  Primary  Glaucoma. 

Primary  glaucoma  is  spontaneous,  usually  bilateral,  and 
may  be  acute  or  chronic,  with  a  varying  increase  of  intra- 
ocular tension.  In  the  acute  form  we  have  all  the  ex- 
ternal signs  of  inflammation  :  Redness,  pain,  edema  of  the 
conjunctiva  and  iris  ;  in  the  chronic  form  these  are  absent 
most  or  all  of  the  time.  Primary  glaucoma  is  therefore 
subdivided  into  inflammatory  and  non-inflammatory  or 
simple  glaucoma,  although  the  latter  may  at  any  time 
change  to  the  inflammatory  form. 


204  EXTERNAL  DISEASES  OF  THE  EYE. 

((.  Inflammatory  Glaucoma. — We  subdivide  this 
again  into  acute  and  ehronic  inflammatory  glaucoma,  bear- 
ing in  mind  that  the  acute  form  often  changes  to  the 
chronic. 

Inflammatory  glaucoma  is  usually  preceded  by  prodro- 
mata,  such  as  headache,  dragging  and  pain  in  the  temple, 
and  occipital  neuralgia ;  the  visual  acuity  is  variable,  and 
the  patient  complains  of  a  haziness  before  his  eyes,  as  if 
he  were  surrounded  by  smoke  or  fog.  If  he  looks  at  a 
light  during  one  of  these  prodromal  attacks,  it  appears  to 
him  surrounded  by  an  iridescent  halo,  the  cause  of  which 
is  found,  on  examination,  to  be  a  slight  haziness  of  the 
corneal  surface.  The  cloudiness  is  most  pronounced  in 
the  central  portion,  which  resembles  the  appearance  of 
glass  the  surface  of  which  has  been  breathed  upon. 
There  is  also  some  shallowing  of  the  anterior  chamber — 
i.  e.,  the  iris  and  Jens  are  displaced  forward  ;  the  pupil  is 
somewhat  dilated  and  reacts  slowly  to  light.  Sometimes 
there  is  ciliary  congestion.  A  prodromal  attack  of  this 
kind  may  last  several  hours,  the  eye  becoming  quite 
normal  again  afterward.  The  intervals  between  the 
attacks  become  progressively  shorter.  They  may  be  in- 
duced in  various  ways,  by  emotional  excitement  of  any 
kind,  pleasurable  or  painful,  by  a  hearty  meal,  by  bend- 
ing over,  etc.  ;  or  they  may  occur  without  any  demon- 
strable cause.  The  prodromal  stage  may  be  protracted  for 
weeks,  months,  or  even  years  ;  but  in  the  last  case  per- 
manent alterations  result — congestion  of  the  anterior 
ciliary  vessels,  excavation  of  the  nerve-head,  and  impaired 
vision. 

An  outbreak  of  fully  developed  glaucoma  (glaucoma 
evolutum)  is  characterized  by  the  following  symptoms : 
Violent  pain  in  the  eye  and  headache,  which  soon  become 
unbearable  and  rob  the  sufferer  of  sleep  and  appetite, 
accompanied  by  intense  congestion  of  the  eyeball.  Edema 
of  the  lids  occurs,  and  in  severe  cases  of  the  bulbar  con- 
junctiva. There  is  rapid  loss  of  vision,  which  is  almost 
^.    absolute  in  the  affected  eye.     If  the  attack  is  a  severe  one, 


GLAUCOMA.  205 

the  patient  vomits  as  long  as  it  lasts  and  usually  takes 
to  his  bed,  with  every  appearance  of  severe  illness. 
The  characteristic  objective  signs  are  diffuse  haziness 
of  the  cornea ;  shallowing  of  the  anterior  chamber ;  al- 
teration in  the  shape  of  the  pupil,  which  is  dilated  and 
may  be  irregular,  oval  with  its  long  axis  vertical  or  ob- 
liquely placed,  or  decentered ;  reaction  to  light  imperfect 
or  absent.  A  greenish  reflex  is  seen  in  the  depths  of  the 
pupil  (Plate  36,  a),  from  which  the  name  of  the  disease  is 
taken  (green  cataract),  although  there  is  nothing  charac- 
teristic about  it,  since  it  is  observed  in  most  elderly  people 
when  the  pupil  is  dilated.  Its  presence  in  glaucoma 
becomes  apparent  on  account  of  the  dilatation  incident  to 
the  disease,  and  is  due  chiefly  to  sclerosis  of  the  lens,  com- 
plicated in  some  cases  with  a  slight  turbidity  of  the  vit- 
reous. Upon  inspection  with  the  ophthalmoscope  the 
eye-ground  is  seen  imperfectly  or  not  at  all,  owing  to  the 
opacity  of  the  cornea  and  the  turbidity  of  the  vitreous 
referred  to.  Upon  palpation  the  tension  of  the  eyeball  is 
found  to  be  increased. 

If  treatment  is  delayed,  an  attack  of  this  kind  may  last 
for  days  and  weeks,  and  subside  very  gradually,  leaving 
the  visual  acuity  permanently  impaired  and  followed  by 
chronic  congestion  of  the  anterior  ciliary  veins,  dilatation 
of  the  pupil,  immobility  and  atrophy  of  the  iris,  and  re- 
duction in  the  depth  of  the  anterior  chamber  (Plate  3(3,  a). 
In  many  cases  the  visual  field  shows  marked  restriction  on 
the  nasal  side.  The  optic  nerve  is  more  or  less  excavated 
and  discolored  from  atrophy,  particularly  in  the  temporal 
half. 

Hemorrhagic  glaucoma,  a  most  malignant  form  of  the 
disease,  gives  rise  to  hemorrhages  in  the  retina,  which  are 
detected  with  the  ophthalmoscope,  and  sometimes  into  the 
anterior  chamber  and  into  the  vitreous. 

When  the  glaucomatous  habit  is  once  established,  the 
attacks  occur  again  and  again  in  slightlv  decreasing  sever- 
ity.  Each  successive  attack  increases  the  deterioration  of 
vision  and  damage  to  the  optic  nerve,  until  finally  perma- 


206  EXTERNAL   DISEASES  OF  THE  EYE. 

Plate  36. 

a.  Acute  Glaucoma. — E.  B.,  a  woman  of  71  years,  underwent  an  opera- 
tion for  cataract  in  the  left  eye  seven  years  ago  (without  iridectomy), 
and  since  that  time  enjoyed  perfectly  good  vision,  the  posterior  capsule 
having  been  removed  by  discission  shortly  after  the  operation.  The 
pupil  was  round  and  movable.  Two  days  ago  she  was  suddenly  seized 
with  pain  in  the  eye  and  dimness  of  vision,  without  apparent  cause.  Her 
condition  improved  at  fiist  after  the  administration  of  myotics,  and  visual 
acuity  returned  to  '■.  Another  acute  attack  occurred  in  the  clinic,  with 
tension  of  T  2,  redness  of  the  eye.  and  dilatation  of  the  pupil  (see 
illustration),  which  was  displaced  slightly  upward,  as  frequently  happens 
in  glaucoma.  The  surface  of  the  eyeball  was  cloudy,  and  a  grayish-green 
reflex  was  observed  in  the  deep  portions  of  the  eye.  Sclerotomy  and 
thorough  discission  were  performed,  and  by  continued  use  of  physostig- 
min  and  pilocarpiu  the  patient  was  finally  cured,  with  a  visual  acuity 
of  i 

b.  Spicule  of  Iron  in  the  Vitreous  (Extracted) ;  Laceration  of  the  Iris, 
Traumatic  Cataract,  and  Turbidity  of  the  Vitreous.— V.  Seh..  a  peasant 
woman,  60  years  old,  got  a  piece  of  iron  in  her  left  eye  while  hoeing 
potatoes  on  June  14,  1897.  The  next  day  she  went  to  a  doctor,  who  pro- 
nounced the  wound  superficial  and  of  no  consequence.  The  patient  did 
not  feel  pain  at  any  time,  but  complained  of  a  thick  haziness  immediately 
after  the  injury.  When  she  was  admitted  to  my  private  hospital,  on  the 
17th,  the  eye  was  inflamed  and  the  channel  of  the  wound  plainly  seen 
(see  figure).  The  wound  consisted  of  a  rent  in  the  cornea  (where  the 
foreign  body  had  entered),  a  little  below  the  center,  appearing  as  a  fine, 
gray  line  1.5  mm.  in  length  ;  a  laceration  in  the  iris,  traumatic  cataract, 
and  a  triangular  wound  in  the  posterior  capsule.  The  iris  was  adherent 
to  the  wound  in  the  anterior  capsule.  The  pupillary  reflex  was  greenish, 
and  by  lateral  illumination  a  metallic  luster  was  seen  in  the  opacity  of  the 
posterior  cortex.  The  foreign  body  was  not  visible,  although  undoubtedly 
present  in  the  vitreous.  On  approaching  the  large  electromagnet  it  was  at 
once  drawn  into  the  anterior  chamber,  from  which  it  was  removed 
through  the  original  point  of  entrance  (June  17).  On  the  27th  the  in- 
flammation had  practically  disappeared,  and  on  the  29th  the  woman  was 
discharged.  All  inflammatory  symptoms  had  subsided  and  the  patient 
was  able  to  count  fingers  at  2  meters.  On  July  9  the  visual  acuity  was 
still  the  same  and  the  cataract  had  not  progressed;  the  fundus  also  was 
plainly  visible. 


nent,  absolute  blindness  supervenes  and  the  eye  presents 
the  appearances  characteristic  of  absolute  glaucoma:  The 
cornea  is  less  opaque  than  in  the  earlv  stages,  and  is  sur- 
rounded by  a  wreath  of  dilated  blood-vessels  ;  the  anterior 


Tab.  36. 


mmm 


Lith.AnM  E Retchhold.  München. 


GLAUCOMA.  207 

chamber  is  excessively  shallow ;  the  iris  reduced  to  a 
narrow  ribbon  or  completely  obliterated  in  places  (Plate 
40).  The  pupil  is  widely  dilated  and  immovable,  and 
shows  a  greenish  reflex  shining  through.  The  papilla  of 
the  optic  nerve  is  deeply  excavated  in  its  entire  circumfer- 
ence and  the  eyeball  is  as  hard  as  stone.  From  time  to 
time  the  eye  is  quite  painful,  and  eventually  degenerates, 
while  the  cornea  becomes  permanently  obscured  and  cov- 
ered with  glassy  deposits  and  hypertrophic^!  folds.  The 
sclera  may  exhibit  ectasia  about  the  cornea  or  in  the 
equatorial  region.     The  lens  becomes  cataractous. 

The  course  of  chronic  inflammatory  glaucoma  is  slower 
than  that  of  the  acute  variety,  which  sometimes  takes  the 
form  of  fulminating  glaucoma  and  utterly  destroys  the 
eyesight  in  a  few  hours. 

b.  Non-inflammatory  or  Simple  Glaucoma.— 
In  this  treacherous  form  of  glaucoma  the  visual  deteriora- 
tion imperceptibly  goes  on  to  complete  blindness  without 
the  patient's  being  aware  of  distinct  attacks  or  of  pain 
and  inflammation.  The  examining  surgeon  often  finds 
one  eye  irremediably  injured  or  absolutely  blind,  and  the 
other  more  or  less  amblyopic  ;  rise  in  tension  is  barely 
perceptible  or  even  absent ;  but  the  optic  nerve  is  found 
to  be  excavated.  By  testing  the  tension  repeatedly  at 
various  times  of  the  clay,  however,  especially  early  in  the 
morning,  the  cardinal  symptom  can  usually  be  obtained, 
and  on  careful  inquiry  the  patient  admits  that  he  has  had 
slight  pain  and  dimness  of  vision.  The  loss  of  vision 
usually  begins  at  the  circumference  of  the  field  of  vision, 
the  restriction  being  most  noticeable  at  first  on  the  nasal 
side.  Central  vision  is  also  affected  to  a  corresponding 
extent,  although  it  is  relatively  better  up  to  a  certain 
period  in  the  disease.  The  disease  always  affects  both 
eyes,  and  may  be  protracted  for  years,  eventually  passing 
into  the  inflammatory  or  the  hemorrhagic  form.  In  some 
cases  of  simple  glaucoma  the  degeneration  of  the  optic 
nerve  is  probably  hastened  by  the  abnormal  loss  of  rigid- 
ity of  the  lamina  cribrosa. 


208  EXTERNAL  DISEASES  OF  THE  EYE. 

Generally  speaking,  glaucoma  is  a  disease  of  advanced 
life.  Inflammatory  glaucoma  is  rare  before  the  fiftieth 
year ;  simple  glaucoma  sometimes  occurs  before  that  age. 
Occasionally  the  process  is  met  with  in  children. 

Infantile  Glaucoma. — The  changes  produced  by 
glaucoma  in  the  growing  eye  include  abnormal  enlarge- 
ment, which  is  never  observed  in  the  adult  (if  we  except 
the  ectasias  which  occur  in  the  degenerative  stage),  no 
matter  how  long  the  rise  in  tension  continues.  Buph- 
thalmo8  or  hydrophthalmos  develops  if  the  process  is  not 
arrested.  The  first  symptom  observed  is  the  characteristic 
cloudiness  of  the  surface  of  the  cornea,  followed  shortly 
by  diffuse  opacity  of  the  entire  membrane,  which  becomes 
enlarged  and  covered  with  spots.  Upon  careful  examina- 
tion a  peculiar  network  of  ribbon-like  streaks  is  seen  in 
the  depths  of  the  corneal  tissue.  This  phenomenon  per- 
sists after  the  tension  has  returned  to  the  normal,  and 
furnishes,  in  the  writer's  opinion,  an  important,  albeit 
somewhat  tardy,  support  to  the  diagnosis.  The  dilatation 
of  the  pupil  and  shallowing  of  the  anterior  chamber  are 
less  marked  than  in  the  adult  form,  and,  if  the  cornea  has 
become  enlarged,  the  anterior  chamber  will  appear  ab- 
normally deep.  Excavation  of  the  optic  nerve  is  not 
slow  to  develop  in  most  cases.  The  disease  usually  affects 
both  eyes.  The  children  exhibit  photophobia  and  usually 
appear  to  feel  some  pain,  so  that  considerable  difficulty 
is  experienced  in  making  an  examination.  As  it  is  quite 
impossible  to  make  a  satisfactory  test  of  the  tension  if  the 
infant  struggles  and  cries,  anesthesia  is  usually  employed 
for  the  entire  examination,  including  inspection  with  the 
ophthalmoscope.  In  rare  instances  the  disease  tends  to 
spontaneous  cure  ;  but,  as  a  rule,  it  goes  on  to  complete 
destruction  if  not  checked  by  the  proper  treatment. 
Sooner  or  later  the  child  strikes  against  some  object  in  his 
surroundings,  and  the  weakened  membranes  burst  and 
shrivel   up. 

Glaucoma  occurs  shortly  after  birth  or  during  the  first 
few  years  of  life.     It  is  unknown   in   later  childhood. 


GLAUCOMA.  209 

It  may  be  stated,  in  general,  that  myopic  eyes  almost 
never  become  affected  with  inflammatory  glaucoma,  but 
may  be  attacked  by  the  simple  form.  Arterial  sclerosis 
and  cardiac  weakness  are  predisposing  causes.  The 
mechanism  of  glaucoma  is  not  well  understood.  The  rise 
in  tension  is  thought  to  be  caused  by  increased  secretion 
of  fluid  within  the  eye  (von  Graefe's  serous  choroiditis) 
and  by  obstruction  to  the  normal  outflow  from  changes  in 
the  eye  (obstruction  to  the  outflow  in  the  anterior  chamber 
in  the  form  of  circular  adhesions  between  the  periphery 
of  the   iris  and  the  cornea,    Knies   and  Weber  theory). 

Dilatation  of  the  pupil  with  atropin  is  positively 
known  to  bring  on  glaucoma  if  the  eye  is  predisposed  to 
the  disease  or  has  already  suffered  an  attack. 

Diagnosis. — Inflammatory  glaucoma  is  very  apt  to 
be  confounded  with  iritis;  and  the  differential  diagnosis  is 
of  the  highest  importance,  as  the  two  conditions  demand 
radically  different  treatment.  It  should  be  made  a  rule 
of  practice  never  to  use  atropin  until  the  tension  has  been 
accurately  determined.  In  iritis  the  pupil  is  contracted  ; 
in  inflammatory  glaucoma,  dilated.  The  recognition  of 
simple  glaucoma  depends  on  an  ophthalmoscopic  ex- 
amination. A  fatal  error  is  to  mistake  infantile  glau- 
coma for  parenchymatous  keratitis ;  the  two  conditions  are 
very  similar  in  their  external  appearances  during  the  initial 
stage.     The  distinction  is  made  by  observing  the  tension. 

The  prognosis  is  always  grave.  Simple  glaucoma  is 
more  difficult  to  cure  than  the  inflammatory  variety;  but 
the  hemorrhagic  form  is  the  most  hopeless  of  all.  The 
more  precarious  the  condition  of  the  heart  and  blood- 
vessels, the  more  dubious  will  be  the  prognosis  in  a  given 
case  of  glaucoma. 

The  treatment  consists  in  the  local  use  of  myotics, 
physostigmin  or  pilocarpin,  and  in  most  cases  surgical 
operation.  Medicinal  treatment  must  be  begun  at  once  :  3 
to  5  drops  of  a  \  per  cent,  solution  of  physostigmin  (eserin), 
or  5  to  10  drops  of  a  2  per  cent,  solution  of  pilocarpin, 
u 


210  EXTERNAL   DISEASES  OF  THE  EYE. 

Plate  37- 

Sarcoma  of  the  choroid,  which  has  ruptured  anteriorly.  The  patient, 
who  is  53  years  old,  says  he  received  a  severe  blow  Oil  the  left  eye  eleven 
years  ago,  by  running  against  a  beam,  and  that  since  then  vision  gradu- 
ally deteriorated  and  the  eye  sometimes  gave  him  pain.  About  six 
mouths  ago  the  eye  began  to  increase  in  size.  A  large  conical  tumor 
projects  through  the  palpebral  fissure,  and  is  seen  to  be  covered  with  a 
number  of  smaller  nodules  1  hidden  in  part  under  the  upper  lid).  A 
small,  bluish  segment  of  the  cornea  is  seen  below.  The  growth  is  imper- 
vious to  sunlight  even  when  a  lens  is  used.  In  places  it  feels  hard  to  the 
touch.  No  pulsation  in  the  tumor.  No  glandular  swelling  on  the  left 
side  of  the  head.  The  whole  contents  of  the  orbit  were  immediately 
extirpated  and  the  diagnosis  of  sarcoma  confirmed  by  examination  of  the 
specimen  (moderately  pigmented  spindle-cell  sarcoma)  and  by  the  subse- 
quent course,  for  the  man  died  a  year  later  of  a  large  sarcoma  involving 
the  left  half  of  the  pelvis  and  the  inguinal  glands  011  both  sides,  and  of  a 
sarcoma  in  the  right  deltoid  muscle.     The  tumor  did  not  recur  in  situ. 

in-tilled  into  the  eye  every  day.  Pilocarpin  is  the  milder 
of  the  two,  and  is  well  adapted  for  long-continued  use  and 
after  an  operation.  This  is  supplemented  by  subcutaneous 
injections  of  morphin,  which  has  the  double  advantage  of 
inducing  sleep  and  assisting  in  the  production  of  myosis. 
Atropin  is  to  be  strictly  avoided  in  glaucoma. 

The  success  of  an  operation  for  glaucoma  depends  alto- 
gether on  its  being  performed  early  in  the  disease.  Iri- 
dectomy is  the  best  operation  in  inflammatory,  and  sclerot- 
omy in  simple,  glaucoma  in  an  advanced  stage.  In  the 
early  stages  of  simple  glaucoma  iridectomy  may  also  be 
employed.  It  is  often  advisable  to  combine  the  two  opera- 
tions, and  many  cases  require  repeated  sclerotomies  at 
varying  intervals,  the  myosis  meanwhile  being  steadily 
maintained.  The  course  of  the  disease  is  in  most  cases 
marked  by  frequent  relapses,  which  readily  yield  to  proper 
treatment.  But  in  no  case  should  a  patient  lie  left  to 
himself  without  observation  after  the  performance  of  an 
iridectomy.  In  hemorrhagic  glaucoma,  not  iridectomy, 
but  sclerotomy  is  indicated,  combined  with  active  myosis 
and  cardiac  stimulants.  Infantile  glaucoma  can  be  cured 
by  repeated  sclerotomy,  if  begun  early  enough. 


Tab.  37. 


Lith.Arist  F.  Reichlwld,  München. 


DISEASES   OF  THE   ORBIT  211 

2.  Secondary  Glaucoma. 

This  form  of  glaucoma  may  occur  at  any  age  and  as  a 
complication  of  various  diseases.  It  manifests  itself  by 
cloudiness  of  the  cornea,  dilatation  of  the  pupil  (unless 
there  are  annular  adhesions),  and  pain.  Like  the  primary 
form,  it  may  lead  to  loss  of  vision  through  excavation  of 
the  nerve-head. 

Secondary  glaucoma  is  induced  by  the  following  condi- 
tions : 

1.  Any  condition  tending  to  draw  or  push  the  iris  for- 
ward; anterior  synechia?  with  corneal  wounds,  especially 
such  as  bulge  forward,  or  pressure  by  swelling  or  subluxa- 
tion of  the  lens. 

2.  Posterior  displacement  of  the  iris  by  a  lens  which 
has  entered  the  anterior  chamber. 

3.  Pupillary  occlusion. 

4.  Iridocyclitis  with  precipitates  on  the  posterior  sur- 
face of  the  cornea. 

5.  Mechanical  irritation  of  the  ciliary  body  by  a  lens 
in  luxation  or  subluxation. 

6.  Intraocular  tumors,  sarcoma  and  glioma  in  the  sec- 
ond stage  (before  rupture  outward  has  occurred ). 

The  treatment  of  secondary  glaucoma  is  chiefly 
directed  to  the  relief  of  the  condition  which  produced  the 
rise  in  tension.  Anterior  synechia?  must  be  separated  or 
the  attached  portion  of  the  iris  excised  (iridectomy).  A 
dislocated  lens  in  the  anterior  chamber  is  to  be  removed. 
Occlusion  of  the  pupil  demands  an  iridectomy  to  restore 
communication  between  the  anterior  and  posterior  cham- 
bers. In  iritis  combined  with  increased  tension  sclerotomy 
is  indicated  and  often  suffices  to  restore  the  normal  pressure. 


DISEASES  OF  THE  ORBIT. 

i.   Inflammations. 

Inflammation  may  originate  in  the  periosteum  of  the 
orbit,  or  it  may  attack  the  contents  of  the  orbit  primarily. 


212  EXTERNAL  DISEASES  OF  THE  EYE. 

Plate  38. 

a  and  b.  Glioma  of  the  Retina.— The  infant  was  quite  well  up  to  the 
sixth  month  of  its  existence,  at  which  time  she  began  to  squint  with  the 
left  eye.  When  she  was  one  year  old  her  mother  noticed  a  yellowish 
reflex  in  the  pupil,  which  appeared  more  aud  more  distinct  as  the  pupil 
dilated.  A  few  weeks  ago  (the  child  is  now  twenty  months  old)  the 
right  eye  began  to  show  signs  of  failing  vision.  The  left  eye  was  somewhat 
inflamed,  hard  (T  +  1),  and  larger  than  the  right.  The  left  iris  brown, 
the  right  blue.  Left  pupil  dilated  and  rigid,  transmitting  a  bright 
reflex  (see  Fig.  a)  corresponding  to  several  nodules  which  appeared  to 
occupy  the  greater  portion  of  the  vitreous.  The  surface  of  the  tumor 
streaked  with  red,  partly  blood-vessels  and  partly,  no  doubt,  hemor- 
rhages. In  the  right  eye,  in  which  tension  was  normal,  the  pupil  was 
dilated  and  there  was  a  complete,  fuunel-shaped  retinal  separation  ;  the 
eye  appeared  to  be  nearly  blind.  Enucleation  of  both  eyeballs  was 
proposed  and  refused;  but  the  child  was  brought  back  one  year  later  to 
have  the  operations  performed.  At  this  time  there  was  marked  protrusion 
of  the  left  eye  ;  the  cornea  was  increased  to  twice  its  normal  size  and  was 
opaque;  two  days  after  admission  it  ruptured  and  large  masses  of  the 
tumor  protruded  through  the  opening  (Fig.  b).  Four  days  after  admis- 
sion, enucleation  on  the  right  side  and  extirpation  of  the  contents  of  the 
orbit  on  the  left  were  performed.  On  account  of  severe  hemorrhage, 
however,  it  was  impossible  to  sterilize  the  orbit  thoroughly  in  the 
region  of  the  optic  foramen  ;  on  the  next  day  fever  set  in,  and  on  the  day 
following,  scarlet  fever.  Death  two  weeks  after  the  operation,  from 
purulent  meningitis. 

Periostitis  of  the  orbit  is  quite  frequently  met  with. 

Its  usual  seat  is  the  margin,  where  it  produces  thickening 
and  tenderness  on  pressure.  The  thickened  masses  of 
bone  are  not  movable.  Often  there  is  edematous  swelling 
of  the  lids.  An  inflammation  situated  in  the  posterior 
portion  of  the  orbit  is  less  easily  recognized  and  often  very 
difficult  to  distinguish  from  orbital  cellulitis.  It  manifests 
itself  by  protrusion,  with  more  or  less  pain,  and  lessened 
mobility  of  the  eyeball  (Plate  39).  Sometimes  the  nature 
of  the  process  is  not  recognized  until  a  deep-seated  perios- 
titis leads  to  suppuration  and  the  abscess  ruptures  an- 
teriorly, when  the  roughness  of  the  bone  is  felt  with  the 
probe.  The  suppurative  process  may  spread  to  the  cra- 
nium and  cause  meningitis  or  cerebral  abscess.  This 
complication  is  particularly  apt  to  follow  periostitis  of  the 


Tab.  38. 


DISEASES  OF  THE  ORBIT.  213 

roof  of  the  orbit.     A  periostitic  abscess  at  the  orbital 

margin  produces  marked  swelling  and  redness  of  the 
superjacent  area,  and  ruptures  externally.  A  fistula  is 
often"  formed,  through  which  the  roughened  bone  can  be 
felt  with  a  sound  ;  after  discharging  pus  for  some  time 
the  fistula  becomes  closed  by  the  characteristically  con- 
tracted adherent  scar  seen  in  bone-suppuration.  There  is 
usually  a  defect  at  the  corresponding  point  on  the  bone, 
caused  by  the  caries.  Ectropion  of  the  upper  or  lower 
lid  sometimes  develops  from  adhesion  with  the  fistula. 

Orbital  periostitis  develops  after  injuries  and  in  the 
course  of  tuberculosis,  the  immediate  cause  of  the  process 
being  usually  traumatic,  hence  the  upper  outer  and  lower 
inner  margins  of  the  orbit  are  most  liable  to  be  attacked 
by  tuberculous  caries.  Children  commonly  suffer  from 
this  form,  which  is  comparatively  frequent ;  while  in 
adults  syphilis  is  more  likely  to  be  the  causal  factor.  In 
the  tertiary  stage  the  bones  become  thickened  from  peri- 
ostitis ;  suppuration  is  less  common. 

The  treatment  of  suppurative  forms  of  inflammation 
has  for  its  first  object  to  provide  evacuation  of  the  pus 
through  the  skin.  This  is  best  accomplished  by  making 
an  incision  2  to  3  cm.  long  through  the  periosteum  to  the 
bony  margin,  at  the  point  of  greatest  swelling.  The  peri- 
osteum is  then  separated  from  the  bone  by  means  of  a 
curet  and  the  wound  extended  between  the  periosteum 
and  the  bone,  so  as  to  afford  a. good  view  of  the  injury. 
A  drainage-tube  or  strip  of  iodoform-gauze  is  then  intro- 
duced into  the  wound  to  allow  the  pus  to  discharge  freely. 
Caries  of  the  orbital  margin  requires  general  supporting 
treatment  and,  if  necessary,  removal  of  the  necrotic  bone 
with  a  sharp  curet. 

Syphilitic  periostitis  can  usually  be  made  to  disappear 
by  a  vigorous  course  of  blue  ointment  and  potassium 
iodid. 

Inflammation  of  the  cellular  tissue  of  the  orbit  leads  to 
phlegmon  of  the  orbit,  or  retrobulbar  abscess, 
and    manifests    itself   by  severe    external    symptoms,  as 


214  EXTERNAL   DISEASES  OF  THE  EYE. 

Plate  39. 

Exophthalmos   of  the   right   eye,   probably  due  to  periostitis  of  the 

orbit.  Patient  is  a  baker.  20  years  old,  and  was  admitted  to  the  clinic 
011  account  of  grave  symptoms  in  the  right  eye.  which  he  first  noticed 
two  weeks  ago.  After  violent  cold  and  headache  the  eye  became  so 
swollen  that  he  could  not  open  it.  On  raising  the  lid  with  the  finger  he 
found  that  he  saw  double.  The  swelling  soon  subsided,  but  the  diplopia 
remained,  and  the  patient  has  to  keep  the  right  eye  closed  when  he 
walks.  The  eyeball  is  displaced  forward  and  downward,  about  8  mm.  in 
each  direction.  The  movements  are  much  restricted  in  every  direction, 
especially  upward.  When  the  eye  is  turned  to  the  right,  there  is  right 
diplopia;  when  to  the  left,  crossed  diplopia  diminished  abduction  and 
adduction).  When  the  gaze  is  directed  upward  the  image  of  the  right 
eye  is  also  displaced  upward.  Visual  acuity  and  eye-ground  normal. 
Oil  palpating  between  the  orbital  margin  and  the  globe  a  tumor-like 
resistance  is  felt.     The  rhinopharynx  is  normal.     Xo  signs  of  syphilis. 

The  patient's  condition  continued  for  two  weeks  without  change,  and 
then  disappeared  entirely  without  treatment,  first  the  protrusion  and 
then  the  dislocation  downward.  The  cause  is  probably  to  be  sought  in 
a  periostitis,  secondary  to  catarrh  of  the  frontal  sinus. 

marked  edematous  swelling  of  the  lids  and  ocular  con- 
junctiva (chemosis)  and  exophthalmos.  The  movements 
of  the  eyeball  soon  sutler  restriction  and  vision  is  often 
impaired  or  utterly  destroyed.  The  subjective  symptoms 
are  even  more  severe  than  in  periostitis  :  Violent  pain, 
vomiting,  prostration,  and  slow  pulse — altogether  a  very 
alarming  clinical  picture.  The  abscess  may  rupture  and 
discharge  its  contents  through  a  point  on  the  lids,  marked 
by  intense  redness  and  swelling  and  by  fluctuation.  After 
the  pus  is  evacuated  the  inflammatory  symptoms  may 
subside  rapidly  ;  but  a  permanent  visual  deterioration 
usually  remains,  because  orbital  phlegmons  are  very  apt 
to  produce  inflammation  and  atrophy  of  the  optic  nerve. 
The  bulbns  itself  may  suffer  permanent  injury  in  the 
form  of  retinal  separation.  If  the  inflammation  is  very 
severe,  panophthalmitis  may  result,  and,  as  in  the  case  of 
periostitis,  lead  to  fatal  purulent  meningitis  and  cerebral 
abscess. 

Among  the  causes  of   orbital   abscess  may   be   men- 
tioned : 


Oi 
CO 

OS 
Eh 


DISEASES  OF  TUE  ORBIT.  215 

1.  Wounds  which  have  become  secondarily  infected 
(traumatic  or  operative)  and  foreign  bodies  in  the  orbit. 

2.  Purulent  catarrh  of  the  bony  cavities  communicating 
with  the  orbit  (frontal  sinus,  nasal  cavities,  ethmoid  cells, 
antrum).  Periostitis  of  the  orbit  first  develops  and  trans- 
mits the  infection  to  the  orbital  contents. 

3.  Erysipelas  of  the  face,  by  the  inflammatory  poison 
penetrating  to  the  deeper  structure  and  setting  up  an  in- 
flammation in  the  cellular  tissue  of  the  orbit. 

4.  Metastasis  in  pyemia,  typhoid,  scarlet  fever,  influ- 
enza, etc. 

The  treatment  consists  in  removing  the  pus  in  the 
depths  of  the  orbit,  which  may  endanger  the  eye  and 
even  the  life  of  the  patient.  Access  is  obtained  by 
the  same  method  as  that  described  in  periostitis,  and  after 
the  periosteum  has  been  separated  from  the  bone  an  incis- 
ion is  made  in  it  from  behind  forward,  over  the  point 
where  the  pus  is  supposed  to  be,  and  a  drainage-tube  in- 
troduced. 

2.  Injuries  of  the  Orbit. 

Either  the  soft  parts  or  the  bone  may  be  injured.  Fract- 
ure of  the  bone  under  certain  circumstances  gives  rise 
to  emphysema  of  the  lids  (see  p.  107)  and  of  the  cellular 
tissue  in  the  orbit,  showing  itself  in  protrusion  of  the  eye- 
ball. The  latter  can  be  replaced,  but  exophthalmos  reap- 
pears as  soon  as  the  patient  blows  his  nose.  The  partial 
or  total  loss  of  vision  following  a  blow  on  the  bones  of 
the  orbit  or  the  entire  cranium  is  important  from  a  practi- 
cal and  medicolegal  standpoint.  Holder  and  Berlin  have 
shown,  by  their  valuable  investigations,  that  a  fracture  of 
the  base  of  the  skull,  even  when  the  blow  is  received  on 
the  back  or  side  of  the  head,  is  capable  of  producing 
fissures  in  the  roof  of  the  orbit  and  optic  canal.  The 
corresponding  nerve  is  often  so  badly  damaged  by  contu- 
sion or  hemorrhage  that  the  nervous  pathway  is  inter- 
rupted and  total  loss  of  vision  results.  The  patient  on 
recovering  consciousness  is  blind  in  one  or  both  eyes,  and 


216  EXTERNAL   DISEASES  OF  THE  EVE. 

Fig.  C. 

Dermoid  Cyst  of  the  Orbit.— S.  M.,  58  years  old.  In  her  twenty- 
eighth  year  a  tumor  developed  iu  the  inner  cauthus  of  the  left  eye, 
attaining  a  considerable  size  within  three  months  and  then  diminishing 
again.  The  growth  of  the  tumor  was  attended  with  moderate  pain  and 
inflammation.  Two  months  ago  the  neoplasm  again  began  to  grow,  and 
has  increased  rapidly  in  size  during  the  past  three  weeks,  so  that  the 
globe  is  now  displaced  far  to  the  temporal  side,  and  the  woman  often 
complains  of  (crossed)  diplopia.  The  tumor  is  smooth,  the  size  of  a  pig- 
eon's egg.  and  resilient  to  the  touch;  the  lower  portion  is  visible  in  the 
palpebral  fissure  under  the  bulbar  conjunctiva,  and  can  be  felt  for  some 
distance  backward  along  the  bulb.  It  is  freely  movable,  not  adherent  to 
the  bone,  does  not  diminish  on  pressure,  and  shows  no  pulsation.  Left 
lachrymal  dnet  patulous.  Xasal  cavity  normal.  Ophthalmoscopic  ex- 
amination :  On  the  nasal  side  the  wall  of  the  globe  is  turned  in  so  as  to 
simulate  a  slight  retinal  separation  ;  at  the  periphery  the  posterior  por- 
tion of  the  ciliary  body  is  seen  (large,  dark-brown  projections).  The 
diagnosis  of  dermoid  cyst  was  confirmed  after  extirpation.  The  cyst 
extended  along  the  nasal  wall  to  the  posterior  pole  of  the  orbit,  and 
contained  the  characteristic  mushy  material,  with  numbers  of  cilia.  The 
eyeball  returned  to  its  normal  position  and  movement  was  restored. 
Cure  in  seventeen  days. 

a  few  weeks  later  the  atrophy  of  the  nerve  is  demonstra- 
ble with  the  ophthalmoscope.  Fracture  of  the  orbital 
roof  and  optic  canal  may  also  be  caused  by  a  severe  blow 
on  the  upper  or  outer  portion  of  the  orbital  margin.  The 
resulting  blindness  in  these  cases  is  incurable. 

3.  Tumors  of  the  Orbit. 

Orbital  tumors  sooner  or  later  have  the  effect  of  dis- 
placing the  eye  forward.  A  tumor  situated  within  the 
eone  of  the  recti  muscles,  surrounding  the  optic  nerve, 
causes  ;i  displacement  in  the  direction  of  the  orbital  axis  ; 
the  movements  of  the  eye  are  somewhat  restricted,  but 
equally  strong  in  all  directions,  if  the  tumor  is  benign 
(Fig.  E),  whereas  malignant  tumors  very  early  interfere 
with  the  action  of  the  muscles.  If  a  tumor  develops  out- 
side the  cone  <>f  the  muscles  from  one  of  the  orbital  walls, 
the  eyeball  will  be  displaced  toward  the  opposite  side. 
Thus,  a  tumor  beginning  on  the  floor  of  the  orbit  causes 


DISEASES  OF  THE  ORBIT. 


217 


protrusion  and  upward  displacement  (Fig.  F) ;  one  in  the 
nasal  portion  of  the  orbit,  protrusion  and  outward  dis- 
placement (Figs.  C  and  D).  A  deep-seated  tumor  can 
sometimes  be  located  by  palpation  with  the  little  finger 
between  the  globe  and  the  orbital  margin.    The  nature  of 


the  tumor  in  most  cases  can  only  be  surmised  ;  but  it 
may  be  assumed  that  a  tumor  which  grows  slowly  and 
causes  little  pain  and  limitation  of  movement  is  benign  ; 
while  malignant  growths  develop  more  rapidly  and  occa- 
sion a  higher  degree  of  pain  and  functional  disturbance. 
Dermoid  cyst  (Plate  21  and  Fig.  C)  is   one  of  the  more 


218  EXTERNAL  DISEASES  OF  THE  EYE. 

Fig.  D. 

Bone-cyst  Due  to  Ectasia  of  the  Ethmoid  Cells,  the  Frontal  Sinus, 
and  the  Nasal  Cavity.— M.  F.,  carpenter,  2i  years  old.  The  tumor 
first  made  its  appearance  seven  years  ago,  above  the  inner  canthus 
of  the  left  eye,  aud  increased  gradually,  attaining  its  present  size  two 
years  ago.  No  pain  at  any  time;  but  last  winter  there  was  excessive 
lachrymation  from  time  to  time. 

At  present  there  are  no  signs  of  inflammation  aud  the  left  lachrymal 
duct  is  patulous.  The  tumor  is  about  the  size  of  a  pigeon's  egg,  the 
greater  portion  situated  above  the  internal  lateral  ligament,  which  forms 
a  slight  constriction  in  its  lower  portion.  In  the  region  of  the  root  of 
the  nose  it  is  impossible  to  differentiate  by  palpation  between  the  supra- 
orbital margin  and  the  tumor;  but  along  the  upper  outer  border  the 
tumor  can  be  felt  extending  some  distance  into  the  orbit.  The  tumor  is 
tense,  elastic,  and  fluctuating  ;  no  pulsation.  Crossed  diplopia.  Visual 
acuity  aud  fundus  normal.  Upon  extirpation  of  what  was  thought  to 
be  a  dermoid  cyst,  a  fibrous  sac  of  connective  tissue  was  found,  which 
could  not  be  dissected  out,  being  firmly  adherent  to  the  bone  on  its 
upper  and  nasal  sides,  aud  limited  on  the  outer  side  by  a  thin  plate  of 
bone,  the  nasal  wall  of  the  orbit.  The  bony  plate  is  displaced  toward 
the  orbit  and  is  slightly  movable.  The  sac  contained  a  mass  of  thick, 
greenish  or  brownish  gelatinous  material.  After  this  was  removed,  a 
cavity  the  size  of  a  pigeon's  egg  was  exposed,  communicating  above  with 
the  frontal  sinus  and  below  with  the  nasal  cavity,  and  limited  on  the 
orbital  side  partly  by  the  plate  of  bone  and  partly  by  connective  tissue. 
Cure  was  effected  in  three  weeks.  The  plate  of  bone  and  the  eyeball 
gradually  assumed  a  more  nasal  position. 

frequent  benign  tumors.  The  disposition  to  dermoid  cyst 
is  congenital,  but  the  growth  usually  does  not  develop 
sufficiently  to  inconvenience  the  patient  until  quite  late  in 
life.  Its  favorite  seat  is  the  anterior  portion  of  the  orbit, 
a  little  above  either  the  inner  or  the  outer  canthus  ;  but  a 
large  cyst  may  fill  the  greater  part  of  the  orbit  and  cause 
lateral  displacement  of  the  bulb.  Care  must  be  exercised 
not  to  incise  the  cyst  during  the  operation.  In  excep- 
tional cases  I  have  done  this  purposely,  when  the  cyst 
was  very  large  and  partly  situated  behind  the  globe.  I 
made  a  small  incision  in  the  anterior  pole  and  closed  it 
again  after  part  of  the  contents  had  escaped,  so  that  the 
cyst,  while  retaining  a  moderate  degree  of  tension,  was 
quite  easily  removed  in  toto  from  behind  the  bulb. 


DISEASES  OF  THE  OttBTT. 


219 


A  dermoid  cyst  may  be  difficult  to  distinguish  from  a 
cystoid  dilatation  of  the  ethmoid  cells,  the  frontal  sinus, 
or  the  nasal  cavity,  an  example  of  which  is  shown  in  Fig. 
D.  The  differential  diagnosis  is  based  on  the  presence 
of  a  thin  plate  of  bone  between  the  cyst  and  the  globe, 
corresponding  to  the  nasal  wall  of  the  orbit. 


An  orbital  cyst  appearing  shortly  after  birth  should 
always  suggest  encephalocele  or  meningocele,  which  consists 
of  a  hernia-like  protrusion  of  the  dura  mater  into  the 
orbit.  If  the  sac  contains  brain-tissue,  it  is  called  enceph- 
alocele ;  if  only  cerebrospinal  fluid,  meningocele.  The 
lesion  usually  develops  along  the  line  of  a  bone-suture. 
The  most  frequent  seat  in  the  orbit  is  the  suture  between 


220  EXTERNAL   DISEASES  OF  THE  EYE. 

Fig.  E. 

Angioma  of  the  Orbit. — This  tumor  developed  in  the  course  of  ten 
years,  without  giving  rise  to  pain  or  inflammation,  in  the  center  of  the 
orbit,  and  caused  such  enormous  protrusion  of  the  eyeball  that  the 
woman,  who  was  then  41  years  old,  finally  consented  to  have  it  removed. 
Unfortunately  the  tumor,  which  was  evidently  benign,  had  by  this  time 
|  L891  become  so  large  that  enucleation  of  the  globe  had  to  be  performed 
at  the  same  time.  The  visual  acuity  of  the  affected  eye  had  been  dimin- 
ishing for  some  time  and  was  then  reduced  to  f.  This  visual  deteriora- 
tion was  chiefly  due  to  a  macula,  which  I  observed  in  its  initial  stages,  six 
months  after  the  first  appearance  of  protrusion,  and  which  is  illustrated 
in  Fig.  52,  <i.  Lehmann's  Atlases,  vol.  vii.,  second  edition,  which  shows  the 
ophthalmoscopic  image  as  it  appeared  in  1888,  and  in  Fig.  48,  a,  showing  a 
transverse  section  of  the  macula.  In  addition  there  existed  for  some  time  a 
moderate  degree  of  papillitis  (choked  disk),  which  eventually  passed  into 
optic-nerve  atrophy.  At  the  time  of  operation  the  lids  could  not  be  closed, 
the  palpebral  fissure  remaining  open  to  the  extent  of  3  mm.  Ectropion 
had  begun  in  the  lower  lid.  To  the  outer  aud  lower  side  of  the  globe  a 
moderately  hard,  lobulated  tumor  was  felt,  not  fluctuating  and  not  sen- 
sitive on  pressure. 

the  ethmoid  and  frontal  bones,  hence  the  anomaly  is  found 
usually  in  the  upper  inner  portion  of  the  orbit.  The 
tumor  is  covered  with  normal  skin,  diminishes  on  pressure, 
sometimes  with  symptoms  of  cerebral  tension,  and  may 
exhibit  both  circulatory  and  respiratory  pulsation,  trans- 
mitted by  the  brain.     It   is  firmly  attached   to  the  bone. 

Vascular  tumors  are  occasionally  seen  in  the  orbit, 
sometimes  they  take  the  form  of  an  angioma,  less  fre- 
quently that  of  aneurysm.  A  cavernous  tumor  may  attain 
a  considerable  >ize  (Fig.  E). 

Malignant  tumors  of  the  orbit  are  of  the  greatest  im- 
portance, as  they  threaten  the  patient's  life.  Sarcoma 
in  its  various  forms  is  the  tumor  that  occurs  most  fre- 
quently. It  may  originate  in  the  bone,  the  periosteum, 
the  muscles,  the  lachrymal  gland,  the  connective  tissue  in 
the  orbit,  or  the  sheath  of  the  optic  nerve.  A  sarcoma 
in  the  choroid  may  break  through  into  the  orbit  and  con- 
tinue to  grow  toward  the  front  of  the  eye  (Plate  37). 

The  rare  cases  of  primary  orbital  carcinoma  usually 
begin  in  the  lachrymal  gland.     On  the  other  hand,  carci- 


DISEASES  OF  THE  ORBIT. 


221 


noma  of  the  lids  or  of  the  conjunctiva  may  extend  into 
the  orbit,  or  it  may  break  through  from  the  adjacent  bony 
cavities,  especially  the  antrum  of  Highmore  (Fig.  F). 
Early  recognition  of  the  last-named  condition  is  most 
important,  as  operation  very  soon  becomes  impossible  if 
the  cancer  is  allowed  to  grow  for  any  length  of  time. 
The  nasal  cavity  should  also  be  carefully  examined,  in 


Fig.  E. 


such  cases,  for  possible  exostoses  below  the  lachrymal  sac 
or  the  lower  orbital  margin  and  in  the  temporal  region 
(see  Fig.  F).  If  the  antrum  of  Highmore  is  filled  with 
cancerous  tissue,  the  respiratory  murmur  will  be  heard 
much  better  with  the  stethoscope  at  that  point  than  over 
the  sound  side. 

Malignant  tumors  must  be  extirpated  as  soon  as  possible. 
Krönlein's  method,  which  consists  in  temporary  resection 


222  EXTERNAL   DISEASES  OF   THE  EYE. 

Fig.  F. 

Cancer  of  the  Upper  Maxilla  and  Orbit.— Mrs.  A.  \\ '..  53  years  old. 
Four  months  before  her  first  visit  to  the  clinic  the  patient  had  violent 

toothache  on  the  right  side,  and  although  she  had  several  teeth  extracted 
the  pains  increased  in  severity  and  spread  to  the  right  eye  and  temple. 
As  we  see  in  the  picture,  there  was  even  at  that  time  a  slight  swelling  in 
the  region  of  the  right  upper  jaw  and  temple,  and  the  right  eyeball  was 
displaced  forward  and  upward.  The  movements  of  the  eye  were  restricted 
in  every  direction,  but  especially  downward.  The  patient  was  referred 
to  the  surgical  clinic,  and  extirpation  of  the  tumor  was  performed  by  my 
colleague,  Dr.  Krönlein.  The  whole  upper  jaw.  with  the  exception  of 
part  of  the  palatine  process,  and  the  greater  part  of  the  zygoma  were  re- 
sected. It  was  then  found  that  the  growth  was  much  more  extensive 
than  was  to  be  expected  ;  it  extended  some  distance  backward  on  the  base 
of  the  skull  and  was  laid  bare  as  far  as  the  middle  meningeal  artery. 
The  eyeball  had  to  be  removed,  as  it  was  in  close  relation  with  the  can- 
cerous tissue.  Externally  the  tumor  had  broken  through  the  bone  and 
invaded  the  masseter  muscle.  On  microscopic  examination  it  proved 
to  be  a  squamous  epithelioma.  The  woman  became  extremely  emaciated 
and  died  three  months  later  in  collapse.  There  was  no  recurrence  of  the 
tumor. 


of  the  temporal  wall  of  the  orbit,  affords  the  best  means 
of  access.  The  flap  of  bone  and  soft  tissues  is  replaced 
after  the  tumor  has  been  removed  and  secured  with  sutures. 
A  small  tumor  in  the  temporal  portion  of  the  orbit  can 
often  be  removed  by  this  method  without  sacrificing  the 
globe.  In  extensive  malignant  growths  the  entire  con- 
tents of  the  orbit  must  be  extirpated. 

An  interesting  and  not  very  common  affection  of  the 
orbit  has  received  the  name  pulsating  exophthalmos 
(Plate  40).  It  may  develop  spontaneously  (rarely)  or 
after  a  severe  blow  on  the  skull.  Pulsation  can  be  felt 
at  the  inner  upper  portion  of  the  bulb,  and  the  patient 
complains  of  a  noise  in  his  head  like  the  pounding  of  a 
steam-engine.  A  bruit  can  be  distinctly  heard  on  auscul- 
tation in  the  region  about  the  eye  and  more  faintly  as  far 
back  ;i-  the  occiput,  on  both  the  affected  and  the  unaffected 
sides.  It  is  a  characteristic  sign  that  the  noise  and  pulsa- 
tion disappear  on  compression  of  the  carotid.  Upon  close 
inspection  a  large  pulsating  vein  is  usually  detected  in  the 


DISEASES   OE  THE   ORBIT. 


223 


inner  upper  portion  of  the  bulb.  The  protrusion  can  be 
slightly  reduced  by  continued  pressure.  If  the  condition 
is  neglected,  the  conjunctiva  eventually  becomes  puckered 
into  large,  edematous  folds,  the  superficial  vessels  in  the 
anterior  portion  of  the  globe  become  more  and  more 
dilated,  until  finally  the  lids  are  unable  to  close  and  the 


Fig.  F 


cornea  is  endangered.  The  disease  is  caused  by  traumatic 
fracture  of  the  base  of  the  skull  or  spontaneous  rupture 
of  the  internal  carotid  within  the  cavernous  sinus.  The 
veins  which  carry  the  blood  from  the  orbit  into  the  sinus 
thus  become  engorged  with  arterial  blood  from  the  carotid 
and  pulsate. 

The  surest  treatment  is  ligation  of  the  common  carotid 


224  EXTERNAL    DISEASES   OF  THE  EYE. 

Plate  40. 

Pulsating  Exophthalmos  and  Glaucoma  of  the  Left  Eye.— The  patient 
is  38  yen-  old,  and  a  former  by  occupation.     On  August  14,  1896,  he  fell 

from  a  load  of  grain  ;  did  not  lose  consciousness,  but  bled  freely  from  the 
Dose  and  at  once  became  stone-deaf.  <>n  September  13  the  left  eyeball 
began  to  protrude,  visual  acuity  and  mobility  diminished,  and  b\  the 
middle  of  October,  when  be  was  admitted  to  the  clinic,  all  the  symptoms 
of  pulsating  exophthalmos  had  developed,  except  that  the  patient  did 
not  complain  of  noise  in  the  head,  although  a  pulsating  bruit  could  be 
heard  with  the  stethoscope  all  over  the  head.  The  increasing  protrusion 
of  the  globe,  however,  became  more  and  more  distressing  (at  one  time  a 
small  corneal  ulcer  developed-,  and  the  patient  consented  to  ligation  of 
the  carotid,  which  was  performed  by  Dr.  Krönlein  on  November  20.  At 
first  the  result  appeared  to  be  favorable  :  but  in  the  course  of  the  next 
six  months  marked  exophthalmos  again  developed  and  became  further 
complicated  with  glaucoma.  The  latter  is  responsible  for  the  dilatation 
of  the  pupil  and  disappearance  of  the  iris  under  the  lower  margin  of  the 
cornea,  seen  in  the  picture.  The  anterior  chamber  is  shallow  and  con- 
tains a  small  hyphema.  Fundus  not  visible,  only  red  light.  T  -J.  As 
the  region  of  the  supraorbital  vein  (above  the  inner  can  thus)  was  much 
swollen  and  the  vein  itself  exhibited  pulsation  and  bruit.  1  advised  the 
patient  to  have  the  other  carotid  ligated.  which  was  done  by  Dr.  Krön- 
lein  on  July  30.  The  exophthalmos  subsided  almost  completely  and 
the  subjective  condition  improved,  although  the  glaucoma  remained. 
The  vision  of  the  left  eye  and  hearing  are  permanently  destroyed,  but 
the  man  is  able  to  work. 

of  the  same,  and  if  necessary  of  the  opposite,  side.  In 
sr.iiic  cases  digital  compression  of  the  carotid  suffices  to 
effect  a  cure. 


o 

-d 
od 


I  N  DEX 


Abscess  of  lachrymal  sac,  86 

retrobulbar,  213 
Accommodation,  method  of  measur- 
ing, 43,  50 

table  of  range  of,  53 
Acne  of  conjunctiva,  135 
Acuteness  of  vision,  38 
Amblyopia,  74 
Aniridia,  188 
Ankyloblepharon,  107 
Anterior  chamber,  examination  of, 

35 
Aphakia,  199 
Atrophy  of  optic  nerve,  59 

Bacteeia  in  conjunctival  sac,  110 

in  lachrymal  sac,  80 
Blennorrhea  neonatorum,  113.    See 

( 'onjunctivitis,  gonorrheal. 
Blepharitis,  eczematous,  94  ;  Pis.  4,  6 

squamous,  97 
Blcpbarochalasis,  104;  Pis.  8,  9 
Blepharophimosis,  107 
Buphthalmos,  208 

Cataract,  189 

anterior  polar,  191 ;  PI.  34 

capsular,  114,  189  ;  PI.  34 

complicated,  196 

congenital,  195 

diagnosis  of,  196 

incipient,  193 

partial  stationary,  191 

perinuclear,  zonular,  or  lamellar, 
192;  PI.  33 

posterior  polar,  191 

progressive,  193 

senile,  193,  194  ;  Pis.  32,  33 

traumatic,  195;  Pis.  32,  36 

treatment  of.  197 
Cataracta  accreta.  196 

intumescens,  193 

matura,  193 

nigra,  194 

15 


Catarrh,  eczematous,  131 
Chalazion,  102;  PI.  7 
Choroid,  sarcoma  of,  PI.  37 
Ciliary  body,  diseases  of,  177 
gummata  of,  182 
tumors  of,  188 
Color-blindness,  60 

detection  of,  62 
Color-sense,  contrast-test  for,  61 

perimeter-test  for,  57 
Congestion,    ciliary   or    circumcor- 
neal,  27 

conjunctival,  27 

diagnostic  value  of,  30 

localized  ciliary,  30 
Conjunctiva,  acne  of,  135 

burns  of,  139;  PI.  19 

diseases  of,  110 

ecchymoses  of,  139 

eczema  of,  129,  132;  Pis.  17,  18 

essential  shrinking  of,  131.     See 
Pemphigus. 

foreign  bodies  in,  138 

hyphema  conjunctiva,  PI.  14 

ichthyosis  of,  134 

in  leprosy,  138 

in  scleritis,  135 

in  variola,  135 

syphilomata  of,  138 

tuberculosis  of,  136 

tumors  of,  141 

ulcers  of,  110,  114,  132.  136 
Conjunctivitis,    diphtheritic,    119; 
PI.  13 

eczematous,  129,  132 

etiology  of,  110 

follicular,  112 

gonorrheal,  113;  PI.  12 
treatment  of,  117 

granular,  121.  123,  128 

phlyctenular,  129 

scrofulous,  129 

simple  catarrhal.  109,  111 

spring-,  126,  132;  PI.  15 

225 


226 


INDEX. 


Cornea,  barns  of,  PI.  19 

diseases  of,  143 

examination  of,  31 

injuries  of,  168 

leukomata  of,  33,  115 

macula?  of,  34,  114;  PI.  23 

malformations  of,  169 

milky  opacity  of.   in  spring-con- 
junctivitis, 127 

opacities  of,  34,  114 

transparency  of,  33 

ulcers  of,  159,  162 
Corneal  deposits,  49,  179 

loupe,  46 
Crede's  prophylactic  method,  113 
Cyclitis,  177,179 
Cysts,  dermoid,  87.  150,  217 

prelachrymal,  87 

Dacryocystitis,  83 ;  Pis.  1,  2 

blennorrhceica,  84 

t  reatnient  of,  88 
Dacryostenosis,  78,  79 

symptoms  of,  22 
Deposits,  corneal,  49,  179 
Diffusion-circles,  50 
Diopter,  45 
Diplopia,  63,  67 
Double  images,  66,  72 

Ectasia  of  lachrymal  sac,  83 ;  PI.  3 
Ectopia  lentis  congenita,  198 
Ectropion,  95,  105 
Eczema,  21,  94 

marginal,  95,  128,  130 

of  conjunctiva,  130;  Pis.  17,  22 

of  cornea,  130;  Pis.  22.  23 

of  eyelids,  94 

pustule  or  phlyctenule,  131 
Emmetropia  52 
Encephalocele,  219 
Entropion,  95,  122;  PI.  9 
Epicanthus,  104  ;  Pis.  3,  9 
Epiphora,  78 

hypopyon-keratitis,  82 
Episcleritis  173 
Erysipelas  of  eyelids,  92 

of  lachrymal  sac,  86 
Eversion,  23,  24 

Examination  of  anterior  chamber, 
35 

of  eye  by  lateral  illumination,  46 
by  transmitted  light,  t-^ 
Exophthalmos,  PI.  39 

pulsating,  222;  PI.  10 


Eyeball,  inspection  of,  26 

tension  of.  :;•• 
Eyelids,  anomalies  of,  104 

diseases  of,  92 

eczema  of,  94 

erysipelas  of,  92 

eversion  of,  23 

herpes  zoster  of,  92 

injuries  of,  107 

seborrhea  of,  97 

tumors  of,  108 

Facets  in  cornea,  32 

False  images,  70 

Field    of    vision,    55.      See    Visual 

field. 
Fistula,  lachrymal,  83;  PI.  3 
Foreign  bodies  in  conjunctiva,  138  ; 
PI.  16 
in  cornea,  33;  PI.  21 
in  sclera,  174 
Fruejahr's  catarrh,    126,    132.     See 
Conjunct  iritis,  spring-. 

Glaucoma,  198;  PL  40 
fulminating,  207 
hemorrhagic,  205 
infantile,  169,  208 
primary,  203 

absolute,  206 

acute,  PI.  36 

evolutum,  204 

inflammatory,  204 
secondary,  163*  196,  211 
simple,  207 
Glioma  of  retina.  PI.  38 
Granulations,  follicular,   121 
papillary,  121 
pavement  or  tessellated.  126 

Hemianopsia,  55,  59 
Herpes  cornea?  febrilis,  Pis.  24.  25 
zoster  cornea?,  155 

of  evelids.  92 

ophthalmicus,  PI.  20 
Hordeolum,  K»0;  Pis.  5,  6 
Hydrophtbalmos,  208 
Hypopyon,  35,  178 
Hypopyon-keratitis,  82;  PI.  25 

Ichthyosis  of  conjunctiva,  134 
Images,  double,  in  paralysis,  66,  72 

false,  70 
[rideremia,  188 
Iridocyclitis,  180 


INDEX. 


227 


Iridocyclitis,  traumatic,  183 

ti'eatrnent  of,  187 
Iridodialysis,  187 
Iris,  adhesions  of,  154 

diseases  of,  17? 

injuries  of,  187 

lacerations  of,  PI.  36 

prolapse  of,  150 

tremor  of,  35 

tumors  of,  PI.  30 
Iritis,  117 

diagnosis  of,  185 

gonorrheal,  182 

idiopathic.  183 

rheumatic,  182 

serous,  180 

syphilitic,  176,  181;  PI.  31 

treatment  of,  185 

Keratitis,   eczematous  or  phlyc- 
tenular, 149 
fascicular,  132,  151 
marginal,  128,  130,  151 
neuroparalytic,  155,  163 
parenchymatous,  143  ;  PI.  28 
sclerosing,  148,  172 ;  PI.  29 
scrofulous,  149 

Keratoconus,  32,  170 

Lachrymal  apparatus,  diseases 

of,  78 
sac,  abscess  of,  86 
bacteria  in,  80 
ectasia  of,  83  ;  PL  3 
furuncle  of,  86 
tumor,  83 
Lens,  abnormal  coloration  of,  36 
diseases  of,  188 
dislocation  of,  198 ;  PI.  34 
subluxation  of,  198 
Leprosy  of  conjunctiva,  138 
Leukomata,  33 
Light-perception,  43 
Light-sense,  59 
Lipomatosis,  104 
Loupes,  corneal,  4(5,  49 
Luxatio  lentis,  198 

Malingerers,  detection  of,  74 
Megalocornea,  169 
Membrane,  persistent  pupillary,  185 
Meningocele,  219 
Meter-lens,  45 

Migratory  pustule.   132,   151.      See 
Keratitis,  fascicular. 


Milium,  109 

Mobility,  disturbances  of,  62 

Molluscum  contagiosum,  108;  PI.  6 

Mucocele,  83 

Muscse,  190 

Muscles,  ocular,  action  of,  63 

paralyses  of,  62,  68,  69 
Mydriasis,  traumatic,  187 
Myopia,  52 

Nictitatio,  112 
Nyctalopia,  60 

Opacities  of  cornea,  34,  114 
Ophthalmia,  Egyptian  or  granular, 
121.     See  Trachoma. 

neonatorum,  113.     See  Conjuncti- 
vitis,  gonorrheal. 
Ophthalmitis,  sympathetic,  184 
Optic-nerve  atrophy,  59 
Orbit,  abscess  of,  213 

diseases  of,  211 

injuries  of,  215 

tumors  of,  150,  216,  217,  220 
Osteoma  of  ethmoid,  87 

Pannus,  122 ;  PI.  28 

eczematous  or  scrofulous,  150 

phlyctenular  marginal,  132 

treatment  of,  126 
Panophthalmitis,  114,  163,  201;  PI. 

35 
Papillomacular  bundle,  disease  of, 

59 
Paralyses,  66,  68,  69 

false  images  in,  66 
Pemphigus  of  conjunctiva,  134 
Perimeter,  57 
Photometer,  60 

Phthisis  bulbi,  163,  180,  181 ;  PI.  28 
Pinguecula,  140 
Pityriasis  of  conjunctiva,  134 
Presbyopia,  53 
Protrusion,  22 
Pseudopterygium,  139 
Psoriasis  of  conjunctiva,  134 
Ptervgium,  140;  Pis.  16,  26 
Ptosis,  104 

congenital,  106 
Pupil,  abnormal  coloration  of,  36 

occlusion  and  exclusion  of,  178 

reaction  of,  to  light,  48 
Pupillary  membrane,  persistent,  185 

Reaction  to  light,  48 


228 


INDEX. 


Ret i na,  detachments  of,  59 

glioma  of,  PI.  38 

pigmentary  degeneration  of,  59 
Retrobulbar  abscess,  213 

Sclera,  diseases  of,  171 

foreign  bodies  in,  174 

injuries  of,  173 
Scleritis,  132,  135,  171 ;  PI.  29 
Scotomata,  55,  59 
Seborrhea,  21 

marginal,  98 
Siderosis,  202 
Squint,  73 

test  for,  22 
Staphyloma,  114,  163,  171 

scleral,  172 
Subluxatio  lentis,  198 
Symblepharon,  106,  139 
Synechia?,  178 
Syphilides,  96,  134 
Syphilomata,  138 


Tension  of  eyeball,  36 

Tonometer,  37 

Trachoma,  121,  123,  128;  Pis.  14,  28 

Transparency  of  cornea,  33 

Trichiasis.  95 

Type-cards,  39,  42 

Ulcers,  marginal  or  catarrhal,  110 
of  conjunctiva,  136 
of  cornea,  159, 162, 167 ;  Pis.  26,  27 

Uveitis,  177 

Variola  of  conjunctiva.  135 
Visual  acuity,  test  for,  38 
field,  abnormalities  of,  59 

methods  of  measuring,  55-57 
Vitreous  body,  abnormal  coloration 
of,  36 

diseases  of,  199 

foreign  bodies  in,  Pis.  35,  36 

suppuration  of,  201 

turbidity  of,  Pi.  36 


Medical  and  Surgical  Works 


PUBLISHED   BY 


W.  B.  SAUNDERS,  925  Walnut  Street,  Philadelphia,  Pa. 


PAGE 

American  Pocket  Medical  Dictionary    .    .  31 
*American  Text-Book  of   Applied   Thera- 
peutics     6 

*American  Text-Book  of  Chemistry  ...  40 
*American  Text-Book  of  Diagnosis  ...  40 
*American  Text-Book  of  Dis.  of  Children  .  11 
*An  American  Text-Book  of  Diseases  of  the 

Eye,  Ear,  Nose,  and  Throat 13 

*An   American  Text-Book  of  Genito-Uri- 

nary  and  Skin  Diseases 12 

*American  Text-Book  of  Gynecology  ...  10 
*American  Text-Book  of  Legal  Medicine  .  40 

American  Text-Book  of  Nursing 40 

*American  Text-Book  of  Obstetrics  ...  7 
*American  Text  Book  of  Pathology  .  .  .  40 
*American  Text-Book  of  Physiology  ...  5 
*American  Text-Book  of  Practice  ....  8 
*American  Text-Book  of  Surgery  ....  9 
Anders' Theory  and  Practice  of  Medicine  .  17 

Ashton's  Obstetrics 39 

Atlas  of  Skin  Diseases 24 

Ball's  Bacteriology 39 

Bastin's  Laboratory  Exercises  in  Botany  .  32 

Beck's  Surgical  Asepsis    ...        37 

Boisliniere's  Obstetric  Accidents 35 

Brockway's  Physics 39 

Burr's  Nervous  Diseases 37 

Butler's  Materia  Medica  and  Therapeutics  20 
Cerna's  Notes  on  the  Newer  Remedies  .  .  28 
Chapin's  Compendium  of  Insanity  ....  31 
Chapman's  Medical  Jurisprudence  ....  37 
Church  and  Peterson's  Nervous  and  Men- 
tal Diseases 15 

Clarkson's  Histology 29 

Cohen  and  Eshner's  Diagnosis 39 

Corwin's  Diagnosis  of  the  Thorax    ....  33 

Cragin's  Gynaecology 39 

Crookshank's  Text-Book  of  Bacteriology  .  23 

DaCosta's  Manual  of  Surgery 19 

De  Schweinitz's  Diseases  of  the  Eye  ...  25 
Dorland's  Pocket  Medical  Dictionary    .    .  31 

Dorland's  Obstetrics 37 

Frothingham's  Bacteriological  Guide  ...  26 

Garrigues'  Diseases  of  Women 30 

Gleason's  Diseases  of  the  Ear 39 

*Gould  and  Pyle's  Curiosities  of  Medicine  .  15 

Grafstrom's  Massage 24 

Griffith's  Care  of  the  Baby 34 

Griffith's  Infant's  Weight  Chart 35 

Gross's  Autobiography 22 

Hampton's  Nursing 35 

Hare's  Physiology 39 

Hart's  Diet  in  Sickness  and  in  Health    .    .  32 

Haynes'  Manual  of  Anatomy 37 

Heisler's  Embryology 40 

Hirst's  Obstetrics 16 

Holmes'   Manual  of  Surgery 40 

Hyde's  Syphilis  and  Venereal  Diseases  .  .  37 
International  Text-Boole  of  Surgery    ...  40 

Jackson's  Diseases  of  the  Eye 40 

Jackson  and  Gleason's  Diseases  of  the  Eye, 

Nose,  and  Throat 39 

Keating's  Pronouncing  Dictionary  ....  22 

Keating's  Life  Insurance 35 

Keen's  Operation  Blanks 32 

Keen's  Surgery  of  Typhoid  Fever  ....  18 


PAGE 

Kyle's  Diseases  of  Nose  and  Throat  ...  40 

Laine's  Temperature  Charts 28 

Lockwood's  Practice  of  Medicine    ....  37 

Long's  Syllabus  of  Gynecology 30 

Macdonald's  Surgical  Diagnosis  and  Treat- 
ment     18 

McFarland's  Pathogenic  Bacteria     ....  26 
Mallory  and  Wright's   Pathological   Tech- 
nique    18 

Martin's  Surgery 39 

Martin's  Minor  Surgery,  Bandaging,  and 

Venereal  Diseases 39 

Meigs'  Feeding  in  Early  Infancy 26 

Moore's  Orthopedic  Surgery .19 

Morris'  Materia  Medica  and  Therapeutics  39 

Morris'  Practice  of  Medicine 39 

Morten's  Nurses'  Dictionary 34 

Nancrede's  Anatomy  and  Dissection  ...  27 

Nancrede's  Anatomy ...  39 

Nancrede's  Principles  of  Surgery  ....  40 
Norris'  Syllabus  of  Obstetrical  Lectures    .  33 

Ogden's  Urinary  Analysis 40 

Penrose's  Diseases  of  Women 20 

Powell's  Diseases  of  Children 39 

Pryor's  Pelvic  Inflammations 40 

Pye's  Bandaging  and  Surgical  Dressing    .  19 

Raymond's  Physiology 37 

Rowland's  Clinical  Skiagraphy 29 

Saundby's  Renal  and  Urinary  Diseases  .    .  21 
*Saunders'  American  Year-Book  of  Medi- 
cine and  Surgery 14 

Saunders'  Medical  Hand-Atlases  .  .  .  .  3,  4 
Saunders'  Pocket  Medical  Formulary  .  .  31 
Saunders'  New  Series  of  Manuals  .  .  .  36,  37 
Saunders'  Series  of  Question  Compends  38.  39 

Sayre's  Practice  of  Pharmacy 39 

Semple's  Pathology  and  Morbid  Anatomy  39 
Semple's  Legal  Medicine.  Toxicology,  and 

Hygiene 39 

Senn's  Genito-UVinary  Tuberculosis    ...  20 

Senn's  Tumors 21 

Senn's  Syllabus  of  Lectures  on  Surgery  .  .  33 
Shaw's  Nervous  Diseases  and  Insanity  .    .  39 

Starr's  Diet-Lists  for  Children 34 

Stelwagon's  Diseases  of  the  Skin 39 

Stengel's  Pathology 16 

Stevens'  Materia  Medica  and  Therapeutics  28 

Stevens'  Practice  of  Medicine 27 

Stewart's  Manual  of  Physiology 33 

Stewart    and    Lawrance's    Medical    Elec- 
tricity      39 

Stoney's  Materia  Medica  for  Nurses  ...  40 
Stoney's  Practical  Points  in  Nursing  ...  23 
Sutton  and  Giles'  Diseases  of  Women  .  25,  37 
Thomas's  Diet-List  and  Sick-Room   Diet- 
ary   34 

Thornton's  Dose-Book  and  Manual  of  Pre- 
scription-Writing     37 

Thresh's  Water  and  Water  Supplies  ...  29 
Van  Valzah  and  Nisbet's  Diseases  of  the 

Stomach 17 

Vecki's  Sexual  Impotence 29 

Vierordt  and  Stuart's  Medical  Diagm  sis    .  24 

Warren's  Surgical  Pathology 21 

Wolff's  Chemistry 39 

Wolff's  Examination  of  Urine 30. 


GENERAL   INFORMATION. 


One  Price.  One  price  absolutely  without  deviation.    No  discounts  allowed, 

regardless  of  the  number  of  books  purchased  at  one  time.  Prices 
on  all  works  have  been  fixed  extremely  low,  with  the  view  to 
selling  them  strictly  net  and  for  cash. 

Orders.  An  order    accompanied  by  remittance  will   receive   prompt 

attention,  books  being  sent  to  any  address  in  the  United  States,  by 
mail  or  express,  all  charges  prepaid.  We  prefer  to  send  books  by 
express  when  possible. 

Cash  or  Credit.  Tu  physicians   of   approved   credit  who  furnish  satisfactory 

references  our  books  will  be  sent  free  of  C.  O.  D.  One  volume 
or  two  on  thirty  days'  time  if  credit  is  desired;  larger  purchases 
on  monthly  payment  plan.    See  offer  below. 

How  to  Send  There  are  four  ways  by  which  money  can  be  sent  at  our  risk. 

Money  by       namely:  a  post-office  money  order,  an  express  money  order,  a 

Mail.  bank-check  (draft),  and  in  a  registered  letter.     Money  sent  in  any 

other  way  is  at  the  sender's  risk.    Silver  should  not  be  sent  through 

the  mail. 

Shipments.  All  books,  being  packed  in  patent  metal-edged  boxes,  neces- 

sarily reach  our  patrons  by  mail  or  express  in  excellent  condi- 
tion. 


Subscription 
Books. 


Miscellaneous 


Books. 


Latest 
Editions. 

Bindings. 


Books  in  this  catalogue  marked  with  a  star  (*)  are  for  sale  by 
subscription  only,  and  may  be  secured  by  ordering  them  through 
any  of  our  authorized  travelling  salesmen,  or  direct  from  the 
Philadelphia  office :  they  are  not  for  sale  by  booksellers.  All 
other  books  in  our  catalogue  can  be  procured  of  any  bookseller 
at  the  advertised  price,  or  directly  from  us. 

We  carry  in  stock  only  our  own  publications,  but  can  supply 
the  publications  of  other  houses  (except  subscription  books)  on 
receipt  of  publisher  s  price. 

In  every  instance  the  latest  revised  edition  is  sent. 

In  ordering,  be  careful  to  state  the  style  of  binding  desired- 
Cloth,  Sheep,  or  Half  Morocco. 


Special  Offer.  To  physicians  of  approved  credit  who    furnish    satisfactory 

Monthly  references  books  will  be  sent  express  prepaid  ;  terms.  15.00  cash 
Payment  upon  delivery  of  books,  and  monthly  payments  of  $5  00  thereafter 
Plan.  until  full  amount  is  paid.  Any  of  the  publications  of  W.  B.  Saunders 

(100  titles  to  select  from)  may  be  had  in  this  way  at  catalogue  price, 
including  the  American  Text-Book  Series,  the  Medical  Hand- 
Atlases,  etc.  All  payments  to  be  made  by  mail  or  otherwise,  free 
ni'  all  expense  to  us, 


SAUNDERS' 
MEDICAL  HAND-ATLASES. 


The  series  of  books  included  under  this  title  consists  of  authorized  translations 
into  English  of  the  world-famous  Lehmann  Medicinische  Handatlanten, 
which  for  scientific  accuracy,  pictorial  beauty,  compactness,  and  cheap- 
ness surpass  any  similar  volumes  ever  published. 

Each  volume  contains  from  50  to  100  colored  plates,  executed  by  the 
most  skilful  German  lithographers,  besides  numerous  illustrations  in  the  text. 
There  is  a  full  and  appropriate  description,  and  each  book  contains  a  con- 
densed but  adequate  outline  of  the  subject  to  which  it  is  devoted. 

One  of  the  most  valuable  features  of  these  atlases  is  that  they  offer  a  ready 
and  satisfactory  substitute  for  clinical  observation.  Such  observation, 
of  course",  is  available  only  to  the  residents  in  large  medical  centers;  and  even 
then  the  requisite  variety  is  seen  only  after  long  years  of  routine  hospital  work. 
To  those  unable  to  attend  important  clinics  these  books  will  be  absolutely  indis- 
pensable, as  presenting  in  a  complete  and  convenient  form  the  most  accurate  re- 
productions of  clinical  work,  interpreted  by  the  most  competent  of  clinical  teachers. 

While  appreciating  the  value  of  such  colored  plates,  the  profession  has 
heretofore  been  practically  debarred  from  purchasing  similar  works  because  of 
their  extremely  high  price,  made  necessary  by  a  limited  sale  and  an  enormous 
expense  of  production.  In  planning  this  series,  however,  arrangements  were 
made  with  representative  publishers  in  the  chief  medical  centers  of  the  world 
for  the  publication  of  translations  of  the  atlases  into  nine  different  languages, 
the  lithographic  plates  for  all  being  made  in  Germany,  where  work  of  this  kind 
has  been  brought  to  the  greatest  perfection.  The  enormous  expense  of  making 
the  plates  being  shared  by  the  various  publishers,  the  cost  to  each  one  was 
reduced  to  practically  one-tenth.  Thus  by  reason  of  their  universal  transla- 
tion and  reproduction,  affording  international  distribution,  the  publishers  have 
been  enabled  to  secure  for  these  atlases  the  best  artistic  and  professional 
talent,  to  produce  them  in  the  most  elegant  style,  and  yet  to  offer  them  at  a 
price  heretofore  unapproached  in  cheapness.  The  great  success  of  the 
undertaking  is  demonstrated  by  the  fact  that  the  volumes  have  already  appeared 
in  nine  different  languages — German,  English,  French,  Italian,  Russian, 
Spanish,   Danish,   Swedish,   and    Hungarian. 

In  view  of  the  unprecedented  success  of  these  works,  Mr.  Saunders  has  con- 
tracted with  the  publisher  of  the  original  German  edition  for  one  hundred 
thousand  copies  of  the  atlases.  In  consideration  of  this  enormous  under- 
taking, the  publisher  has  been  enabled  to  prepare  and  furnish  special  additional 
colored  plates,  making  the  series  even  handsomer  and  more  complete  than 
was  originally  intended. 

As  an  indication  of  the  great  practical  value  of  the  atlases  and  of  the 
immense  favor  with  which  they  have  been  received,  it  should  be  noted  that  the 
Medical  Department  of  the  U.  S.  Army  has  adopted  the  "Atlas  of  Opera- 
tive Surgery  "  as  its  standard,  and  has  ordered  the  book  in  large  quantities  for 
distribution  to  the  various  regiments  and  army  posts. 

The  same  careful  and  competent  editorial  supervision  has  been  secured  in 
the  English  edition  as  in  the  originals.  The  translations  have  been  edited  by 
the  leading  American  specialists  in  the  different  subjects.  The  volumes  are 
of  a  uniform  and  convenient  size  (5  X  lYz  inches),  and  are  substantially  bound. 

(For  List  of  Volunies  in  this  Series,  see  next  page.') 
3 


SAUNDERS'  MEDICAL  HAND-ATLASES. 

VOLUMES  NOW  READY. 

Atlas  of  Internal  Medicine  and  Clinical  Diagnosis.  By  Dr.  Chr. 
Jakok,  of  Erlangen.  Edited  by  Augustus  A.  Eshner,  M.  D.,  Professor 
of  Clinical  Medicine  in  the  Philadelphia  Polyclinic;  Attending  Physician 
to  the  Philadelphia  Hospital.  68  colored  plates,  and  64  illustrations  in  the 
text.     Cloth,  33.00  net. 

"The  charm  of  the  book  is  its  clearness,  conciseness,  and  the  accuracy  and  beauty  of  its 
illustrations.  It  deals  with  facts.  It  vividly  illustrates  those  facts.  It  is  a  scientific  work 
put  together  for  ready  reference." — Brooklyn  Medical  Journal. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  R.  von  Hoemann,  of  Vienna.  Edited 
by  Frederick  Peterson,  M.  D.,  Clinical  Professor  of  Mental  Diseases, 
Woman's  Medical  College,  New  York  ;  Chief  of  Clinic,  Nervous  Dept., 
College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  figures 
on  56  plates,  and  193  beautiful  half-tone  illustrations.  Cloth,  $3.50  net. 
"  Hofmann's  'Atlas  of  Legal  Medicine'  is  a  unique  work.    This  immense  field  finds  in  this 

book  a  pictorial  presentation  that  far  excels  anything  with  which  we  are  familiar  in  any  other 

work. ' ' — Philadelphia  Medical  Journal. 

Atlas  of  Diseases  of  the  Larynx.  By  Dr.  L.  Grünwald,  of  Munich. 
Edited  by  Charles  P.  Grayson,  M.  D.,  Lecturer  on  Laryngology  and 
Rhinology  in  the  University  of  Pennsylvania;  Physician-in-Charge,  Throat 
and  Nose  Department,  Hospital  of  the  University  of  Pennsylvania.  With 
107  colored  figures  on  44  plates,  and  25  text-illustrations.  Cloth,  $2.50  net. 
"Aided  as  it  is  by  magnificently  executed   illustrations  in  color,  it  cannot  fail  of  being  of 

the  greatest  advantage  to  students,  general    practitioners,  and  expert  laryngologists."— St. 

Louis  Medical  and  Surgical  Journal. 

Atlas  Of  Operative  Surgery.  By  Dr.  O.  Zuckerkandl,  of  Vienna.  Edited 
by  J.  Chalmers  DaCosta,  M.  D.,  Clinical  Professor  of  Surgery,  Jefferson 
Medical  College,  Philadelphia  ;  Surgeon  to  the  Philadelphia  Hospital.  With 
24  colored  plates  and  217  text  illustrations.      Cloth,  $3.00  net. 

"  We  know  of  no  other  work  \.hat  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of  oper- 
ative surgery."— Münchener  Medicinische    Wochenschrift. 

Atlas  of  Syphilis  and  the  Venereal  Diseases.  By  Prof.  Dr.  Franz 
Mracek,  of  Vienna.  Edited  by  L.  Bolton  Bangs,  M.  D..  late  Profes-or 
of  Genito-Urinary  and  Venereal  Diseases,  New  York  Post-Graduate  Medi- 
cal School  and  Hospital.  With  71  colored  plates  from  original  water-colors, 
and  16  black-and-white  illustrations.  Cloth,  $3.50  net. 
"A  glance  through  the  bonk  is  almost  like  actual  attendance  upon  a  famous  clinic."— 

Journal  of  the  American  Medical  Association. 

IN  PREPARATION. 
Atlas  of  External  Diseases  of  the  Eye.     By  Dr.  O.  Haar,  of  Zurich. 
Edited  by  G.   E.   de  Schweinitz,   M.  D.,    Professor  of  Ophthalmology, 
Jefferson   Medical  College,  Philadelphia.     With   100  colored  illustrations. 

Atlas  of  Skin  Diseases.  By  Proe.  Dr.  Franz  Mracek,  of  Vienna. 
Edited  by  Henry  YY.  STELWAGON,  M.  I).,  Clinical  Professor  of  Derma- 
tology, Jefferson  Medical  College,  Philadelphia.     With  80  colored  plates. 

Atlas  of  Pathological  Histology.  Atlas  of  Operative  Gynecology. 

Atlas  of  Orthopedic  Surgery,  Atlas  of  Psychiatrv. 

Atlas  of  General  Surgery,  Atlas  of  Diseases  of  the  Ear. 


CATALOGUE    OF  MEDICAL    WORKS.  5 


*AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  Edited  by 
William  H.  Howell,  Ph.  D.,  M.  D.,  Professor  of  Physiology  in  the 
Johns  Hopkins  University,  Baltimore,  Md.  One  handsome  octavo  volume 
of  1052  pages,  fully  illustrated.  Prices:  Cloth,  $6.00  net;  Sheep  or  Half- 
Morocco,  #7.00  net. 

This  work  is  the  most  notable  attempt  yet  made  in  America  to  combine  in 
one  volume  the  entire  subject  of  Human  Physiology  by  well-known  teachers 
who  have  given  especial  study  to  that  part  of  the  subject  upon  which  they  write. 
The  completed  work  represents  the  present  status  of  the  science  of  Physiology, 
particularly  from  the  standpoint  of  the  student  of  medicine  and  of  the  medical 
practitioner. 

The  collaboration  of  several  teachers  in  the  preparation  of  an  elementary  text- 
book of  physiology  is  unusual,  the  almost  invariable  rule  heretofore  having  been 
for  a  single  author  to  write  the  entire  book.  One  of  the  advantages  to  be  derived 
from  this  collaboration  method  is  that  the  more  limited  literature  necessary  for 
consultation  by  each  author  has  enabled  him  to  base  his  elementary  account 
upon  a  comprehensive  knowledge  of  the  subject  assigned  to  him;  another,  and 
perhaps  the  most  important,  advantage  is  that  the  student  gains  the  point  of  view 
of  a  number  of  teachers.  In  a  measure  he  reaps  the  same  benefit  as  would  be 
obtained  by  following  courses  of  instruction  under  different  teachers.  The 
different  standpoints  assumed,  and  the  differences  in  emphasis  laid  upon  the 
various  lines  of  procedure,  chemical,  physical,  and  anatomical,  should  give  the 
student  a  better  insight  into  the  methods  of  the  science  as  it  exists  to-day.  The 
work  will  also  be  found  useful  to  many  medical  practitioners  who  may  wish  to 
keep  in  touch  with  the  development  of  modern  physiology. 

CONTRIBUTORS : 

HENRY  P.  BOWDITCH,  M.  D.,  |  WARREN  P.  LOMBARD,  M.  D., 

Professor  of  Physiology,  University  of 
Michigan. 

GRAHAM  LUSK,  Ph.D., 

Professor  of  Physiology,   Yale   Medica' 
School. 

W.  T.  PORTER,  M.D., 

Assistant  Professor  of  Physiology,  Har- 
vard Medical  School. 

EDWARD  T.  REICHERT,  M.D., 

Professor  of  Physiology,  University   of 
Pennsylvania. 

HENRY  SEWALL,  Ph.  D.,  M.D., 

Professorof  Physiology,  Medical  Depart- 
ment, University  of  Denver. 

"  We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  subjects."  —  London  Lancet. 

"  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  stilus  of  the  science  of  physiology  in  the  Eng- 
lish language." — American  Journal  of  the  Medical  Sciences. 


Professor  of  Physiology,  Harvard  Medi 
cal  School. 

JOHN  G.  CURTIS,  M.  D., 

Professor  of  Physiology,  Columbia  Uni- 
versity, N.  Y.  (College  of  Physicians 

and  Surgeons). 

HENRY  H.  DONALDSON,  Ph.  D., 

Head-Professor  of  Neurology,  Univer- 
sity of  Chicago. 

W.  H.  HOWELL,  Ph.  D.,  M.  D., 

Professor  of  Physiology,  Johns  Hopkins 
University. 
FREDERIC  S.  LEE,  Ph.  D., 

Adjunct  Professorof  Physiology,  Colum- 
bia University,  N.  Y.  (College  of 
Physicians  and  Surgeons). 


IV.    B.    SAUNDERS' 


*AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEU- 
TICS. For  the  Use  of  Practitioners  and  Students.  Edited  by 
James  C.  Wilson,  M.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  Jefferson  Medical  College.  One  handsome  octavo 
volume  of  1326  pages.  Illustrated.  Prices:  Cloth,  $7.00  net;  Sheep  or 
Half- Morocco,  $8.00  net. 

The  arrangement  of  this  volume  has  been  based,  so  far  as  possible,  upon 
modern  pathologic  doctrines,  beginning  with  the  intoxications,  and  following 
with  infections,  diseases  due  to  internal  parasites,  diseases  of  undetermined 
origin,  and  finally  the  disorders  of  the  several  bodily  systems — digestive,  re- 
spiratory, circulatory,  renal,  nervous,  and  cutaneous.  It  was  thought  proper  to 
include  also  a  consideration  of  the  disorders  of  pregnancy. 

The  articles,  with  two  exceptions,  are  the  contributions  of  American  writers. 
Written  from  the  standpoint  of  the  practitioner,  the  aim  of  the  work  is  to  facili- 
tate the  application  of  knowledge  to  the  prevention,  the  cure,  and  the  allevia- 
tion of  disease.  The  endeavor  throughout  has  been  to  conform  to  the  title  of 
the  book — Applied  Therapeutics — to  indicate  the  course  of  treatment  to  be 
pursued  at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  have  been  used 
at  one  time  or  another. 

The  list  of  contributors  comprises  the  names  of  many  who  have  acquired  dis- 
tinction as  practitioners  and  teachers  of  practice,  of  clinical  medicine,  and  of 
the  specialties. 

CONTRIBUTORS : 


Dr.  I.  E.  Atkinson,  Baltimore,  Md. 
Sanger  Brown,  Chicago,  III. 
John  B.  Chapin,  Philadelphia,  Pa. 
William  C.  Dabney,  Charlottesville,  Va. 
John  Chalmers  DaCosta,  Philada.,  Pa. 
I.  N.  Danforth,  Chicago,  111. 
John  L.  Dawson,  Jr.,  Charleston,  S.  C. 
F.  X.  Dercum,  Philadelphia,  Pa. 
George  Dock,  Ann  Arbor,  Mich. 
Robert  T.   Edes,  Jamaica  Plain,  Mass. 
Augustus  A.  Eshner,  Philadelphia,  Pa. 
J.  T.  Eskridge,  Denver,  Col. 
F.  Forchheimer,  Cincinnati,  O. 
Carl  Frese,  Philadelphia,  Pa. 
Edwin  E.  Graham,  Philadelphia,  Pa. 
John  Guiteras,  Philadelphia,  Pa. 
Frederick  P.  Henry,  Philadelphia,  Pa. 
Guy  Hinsdale,  Philadelphia,  Pa. 
Orville  Horwitz,  Philadelphia,  Pa. 
W.  W.  Johnston,  Washington,  D.  C. 
Ernest  Laplace,  Philadelphia,  Pa. 
A.  Laveran,  Pans,  France. 


Dr.  James  Hendrie  Lloyd,  Philadelphia,  Pa. 
John  Noland  Mackenzie,  Baltimore,  Md. 
J.  W.  McLaughlin,  Austin,  Texas. 
A.  Lawrence  Mason,  Boston,  Mass. 
Charles  K.  Mills,  Philadelphia,  Pa. 
John  K.  Mitchell,  Philadelphia,  Pa. 
W.  P.  Northrup,  New  York  City. 
William  Osier,  Baltimore,  Md. 
Frederick  A.  Packard,  Philadelphia,  Pa. 
Theophilus  Parvin,  Philadelphia,  Pa. 
Beaven  Rake,  London,  England. 
E.  Ü.  Shakespeare.  Philadelphia,  Pa. 
Wharton  Sinkler,  Philadelphia,  Pa. 
Louis  Starr,  Philadelphia,  Pa. 
Henry  W.  Stelwagon,  Philadelphia,  Pa. 
James  Stewart,  Montreal,  Canada. 
Charles  G.  Stockton,  Buffalo,  N.  Y. 
James  Tyson,  Philadelphia,  Pa. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich. 
James  T.  Whittaker,  Cincinnati,  O. 
J.  C.  Wilson.  Philadelphia,  Pa. 


"  As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  of 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician."  —  Chicago  Clinical  Review. 

"The  whole  field  of  medicine  has  been  well  covered.  The  work  is  thoroughly  practical, 
and  while  it  is  intended  for  practitioners  and  students,  it  is  abetter  book  for  the  general 
practitioner  than  for  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpful." — The  Indian  Lancet. 


CATALOGUE    OF  MEDICAL    WORKS. 


*AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  Edited  by 
Richard  C.  Norms,  M.  D. ;  Art  Editor,  Robert  L.  Dickinson,  M.  D. 
One  handsome  octavo  volume  of  over  1000  pages,  with  nearly  900  colored 
and  half-tone  illustrations.  Prices:  Cloth,  $7.00;  Sheep  or  Half-Morocco, 
$8.00. 

The  advent  of  each  successive  volume  of  the  series  of  the  American  Text- 
Books  has  been  signalized  by  the  most  flattering  comment  from  both  the  Press 
and  the  Profession.  The  high  consideration  received  by  these  text-books,  and 
their  attainment  to  an  authoritative  position  in  current  medical  literature,  have 
been  matters  of  deep  international  interest,  which  finds  its  fullest  expression  in 
the  demand  for  these  publications  from  all  parts  of  the  civilized  world. 

In  the  preparation  of  the  "American  Text-Book  of  Obstetrics"  the 
editor  has  called  to  his  aid  proficient  collaborators  whose  professional  prominence 
entitles  them  to  recognition,  and  whose  disquisitions  exemplify  Practical 
Obstetrics.  While  these  writers  were  each  assigned  special  themes  for  dis- 
cussion, the  correlation  of  the  subject-matter  is,  nevertheless,  such  as  ensures 
logical  connection  in  treatment,  the  deductions  of  which  thoroughly  represent 
the  latest  advances  in  the  science,  and  which  elucidate  the  best  modern  methods 
of  procedure. 

The  more  conspicuous  feature  of  the  treatise  is  its  wealth  of  illustrative 
matter.  The  production  of  the  illustrations  had  been  in  progress  for  several 
years,  under  the  personal  supervision  of  Robert  L.  Dickinson,  M.  D.,  to  whose 
artistic  judgment  and  professional  experience  is  due  the  most  sumptuously 
illustrated  work  of  the  period.  By  means  of  the  photographic  art,  combined 
with  the  skill  of  the  artist  and  draughtsman,  conventional  illustration  is  super- 
seded by  rational  methods  of  delineation. 

Furthermore,  the  volume  is  a  revelation  as  to  the  possibilities  that  may  be 
reached  in  mechanical  execution,  through  the  unsparing  hand  of  its  publisher. 


CONTRIBUTORS 


Dr.  James  C.  Cameron. 
Edward  P.  Davis. 
Robert  L.  Dickinson. 
Charles  Warrington  Earle. 
James  H.  Etheridge. 
Henry  J.  Garrifues. 
Barton  Cooke  Hirst. 
Charles  Jewett. 


Dr.  Howard  A.  Kelly. 
Richard  C.  Norris. 
Chauncey  D.  Palmer. 
Theophilus  Parvin. 
George  A.  Piersol. 
Edward  Reynolds. 
Henry  Schwarz. 


"At  first  glance  we  are  overwhelmed  by  the  magnitude  of  this  work  in  several  respects, 
viz. :  First,  by  the  size  of  the  volume,  then  by  the  array  of  eminent  teachers  in  this  depart- 
ment who  have  taken  part  in  its  production,  then  by  the  profuseness  and  character  of  the 
illustrations,  and  last,  but  not  least,  the  conciseness  and  clearness  with  which  the  text  is  ren- 
dered. This  is  an  entirely  new  composition,  embodying  the  highest  knowledge  of  the  art  as 
it  stands  to-day  by  authors  who  occupy  the  front  rank  in  their  specialty,  and  there  are  many 
of  them.  We  cannot  turn  over  these  pages  without  being  struck  by  the  superb  illustrations 
which  adorn  so  many  of  them.  We  are  confident  that  this  most  practical  work  will  find 
instant  appreciation  by  practitioners  as  well  as  students." — New  York  Medical  Times. 

Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  1  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers. 

With  profound  respect  I  am  sincerely  yours,  Alex.  J.  C.  Skenh. 


)i:   B.    SAUNDERS' 


*AN     AMERICAN     TEXT-BOOK    OF     THE     THEORY 
PRACTICE  OF  MEDICINE.     By  American  Teachers. 


AND 

Edited 

by  William  Pepper,  M.  D.,  LL.D.,  Provost  and  Professor  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania.  Complete  in  two  handsome  royal-octavo  volumes  of  about 
iooo  pages  each,  with  illustrations  to  elucidate  the  text  wherever  necessary. 
Price  per  Volume  :  Cloth,  $5.00  net;  Sheep  or  Half- Morocco,  $6.00  net. 


VOLUME  I.   CONTAINS: 


Hygiene. — Fevers  (Ephemeral,  Simple  Con- 
tinued, Typhus,  Typhoid,  Epidemic  Cerebro- 
spinal Meningitis,  and  Relapsing). — Scarla- 
tina, Measles,  Röthein,  Variola,  Varioloid, 
Vaccinia, Varicella,  Mumps, Whooping-cough, 
Anthrax,  Hydrophobia,  Trichinosis,  Actino- 


mycosis, Glanders,  and  Tetanus. — Tubercu- 
losis, Scrofula,  Syphilis,  Diphtheria,  Erysipe- 
las, Malaria,  Cholera,  and  Yellow  Fever. — 
Nervous,  Muscular,  and  Mental  Diseases  etc. 


VOLUME   II.  CONTAINS: 

Urine  (Chemistry  and  Microscopy). — Kid-  |  — Peritoneum,  Liver, and  Pancreas. — Diathet- 
ney  and  Lungs. — Air-passages  (Larynx  and  I  ic  Diseases  (Rheumatism,  Rheumatoid  Ar- 
Bronchi)  and  Pleura. — Pharynx,  Oesophagus,  j  thritis,  Gout,  Lithaemia,  and  Diabetes.)  — 
Stomach  and  Intestines  (including  Intestinal  Blood  and  Spleen. — Inflammation,  Embolism, 
Parasites),  Heart,  Aorta,  Arteries  and  Veins.  |  Thrombosis,  Fever,  and  Bacteriology. 

The  articles  are  not  written  as  though  addressed  to  students  in  lectures,  but 
are  exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causa- 
tion, Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large 
number  of  approved  formulae.  The  recent  advances  made  in  the  study 
of  the  bacterial  origin  of  various  diseases  are  fully  described,  as  well  as  the 
bearing  of  the  knowledge  so  gained  upon  prevention  and  cure.  The  subjects 
of  Bacteriology  as  a  whole  and  of  Immunity  are  fully  considered  in  a  separate 
section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without 
consulting  works  specially  devoted  to  the  subject. 


CONTRIBUTORS : 


Dr 


J.  S.  Billings,  Philadelphia. 
Francis  Delafield,  New  York. 
Reginald  H.  Fitz,  Boston. 
James  W.  Holland,  Philadelphia. 
Henry  M.  Lyman,  Chicago. 
William  Osier,  Baltimore. 


Dr.  William  Pepper,  Philadelphia. 
W.  Oilman  Thompson,  New  York. 
W.  H.  Welch,  Baltimore. 
James  T.  Whittaker,  Cincinnati. 
James  C.  Wilson,  Philadelphia. 
Horatio  C.  Wood,  Philadelphia. 


"  \Ve  reviewed  the  first  volume  of  this  work,  and  said :  '  It  is  undoubtedly  one  of  the  best 
text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the  second 
^.nd  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  k,  in  our 
opinion,  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see.  It  is  complete,  thorough, 
accurate,  and  clear.  It  is  well  written,  well  arranged,  well  printed,  well  illustrated,  and  well 
bound.    It  is  a  model  of  what  the  modern  text-book  should  be." — New  York  Medical  Journal. 

"A  library  upon  modern  medical  art.  The  work  must  promote  the  wider  diffusion  of 
sound  knowledge." — American  Lancet. 

"  A  trusty  counsellor  for  the  practitioner  or  senior  student,  on  which  he  may  implicitly 
rely."— Edinburgh  Medical  Journal. 


CATALOGUE    OF  MEDICAL    WORKS. 


*AN  AMERICAN  TEXT-BOOK  OF  SURGERY.  Edited  by  Wil- 
liam W.  Keen,  M.D.,  LL.D.,  and  J.  William  White,  M.  D.,  Ph.  D. 
Forming  one  handsome  royal-octavo  volume  of  1250  pages  (10x7  inches), 
with  500  wood-cuts  in  text,  and  37  colored  and  half-tone  plates,  many  of 
them  engraved  from  original  photographs  and  drawings  furnished  by  the 
authors.     Prices  :  Cloth,  #7.00  net;  Sheep  or  Half- Morocco,  #8.00  net. 

SECOND  EDITION,  REVISED  AND  ENLARGED, 

With  a  Section  devoted  to  "  The  Use  of  the  Röntgen  Rays  in  Surgery." 

The  want  of  a  text-book  which  could  be  used  by  the  practitioner  and  at  the 
same  time  be  recommended  to  the  medical  student  has  been  deeply  felt,  espe- 
cially by  teachers  of  surgery;  hence,  when  it  was  suggested  to  a  number  of 
these  that  it  would  be  well  to  unite  in  preparing  a  text-book  of  this  description, 
great  unanimity  of  opinion  was  found  to  exist,  and  the  gentlemen  below  named 
gladly  consented  to  join  in  its  production.  While  there  is  no  distinctive  Amer- 
ican Surgery,  yet  America  has  contributed  very  largely  to  the  progress  of  modern 
surgery,  and  among  the  foremost  of  those  who  have  aided  in  developing  this  art 
and  science  will  be  found  the  authors  of  the  present  volume.  All  of  tbem  are 
teachers  of  surgery  in  leading  medical  schools  and  hospitals  in  the  United  States 
and  Canada. 

Especial  prominence  has  been  given  to  Surgical  Bacteriology,  a  feature  which 
is  believed  to  be  unique  in  a  surgical  text-book  in  the  English  language.  Asep- 
sis and  Antisepsis  have  received  particular  attention.  The  text  is  brought  well 
up  to  date  in  such  important  branches  as  cerebral,  spinal,  intestinal,  and  pelvic 
surgery,  the  most  important  and  newest  operations  in  these  departments  being 
described  and  illustrated. 

The  text  of  the  entire  book  has  been  submitted  to  all  the  authors  for  their 
mutual  criticism  and  revision — an  idea  in  book- making  that  is  entirely  new  and 
original.  The  book  as  a  whole,  therefore,  expresses  on  all  the  important  sur- 
gical topics  of  the  day  the  consensus  of  opinion  of  the  eminent  surgeons  who 
have  joined  in  its  preparation. 

One  of  the  most  attractive  features  of  the  book  is  its  illustrations.  Very 
many  of  them  are  original  and  faithful  reproductions  of  photographs  taken 
directly  from  patients  or  from  specimens. 

CONTRIBUTORS : 


Dr.  Charles  H.  Burnett,  Philadelphia. 
Phineas  S.  Conner,  Cincinnati. 
Frederic  S.  Dennis,  New  York. 
William  W.  Keen,  Philadelphia. 
Charles  B.  Nancrede,  Ann  Arbor,  Mich. 
Roswell  Park,  Buffalo,  N.  Y. 
Lewis  S.  Pilcher,  New  York. 


Dr.  Nicholas  Senn,  Chicago. 

Francis  J.  Shepherd.  Montreal,  Canada. 

Lewis  A.  Stimson,  New  York. 

William  Thomson,  Philadelphia. 

J.  Collins  Warren,  Boston. 

J.  William  White,  Philadelphia. 


"Jf.*k*s  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  Practice. "— 
London  Lancet. 


IO  W.   B.   SAUNDERS' 


*AN  AMERICAN  TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND  SURGICAL,  for  the  use  of  Students  and  Practitioners. 
Edited  by  J.  M.  Baldy,  M.  D.  Forming  a  handsome  royal-octavo  volume 
of  718  pages,  with  341  illustrations  in  the  text  and  38  colored  and  half- 
lone  plates.     Prices  :  Cloth,  $6.00  net;  Sheep  or  Half-Morocco,  S7.00  net. 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  clear 
understanding  of  the  text,  have  been  omitted,  the  illustrations  being  largely  de- 
pended upon  to  elucidate  the  anatomy  of  the  parts.  This  work,  which  is 
thoroughly  practical  in  its  teachings,  is  intended,  as  its  title  implies,  to  be  a 
working  text-book  for  physicians  and  students.  A  clear  line  of  treatment  has 
been  laid  down  in  every  case,  and  although  no  attempt  has  been  made  to  dis- 
cuss mooted  points,  still  the  most  important  of  these  have  been  noted  and  ex- 
plained. The  operations  recommended  are  fully  illustrated,  so  that  the  reader, 
having  a  picture  of  the  procedure  described  in  the  text  under  his  eye,  cannot  fail 
to  grasp  the  idea.  All  extraneous  matter  and  discussions  have  been  carefully 
excluded,  the  attempt  being  made  to  allow  no  unnecessary  details  to  cumber 
the  text.  The  subject-matter  is  brought  up  to  date  at  every  point,  and  the 
work  is  as  nearly  as  possible  the  combined  opinions  of  the  ten  specialists  who 
figure  as  the  authors. 

In  the  revised  edition  much  new  material  has  been  added,  and  some  of  the 
old  eliminated  or  modified.  More  than  forty  of  the  old  illustrations  have  been 
replaced  by  new  ones,  which  add  very  materially  to  the  elucidation  of  the 
text,  as  they  picture  methods,  not  specimens.  The  chapters  on  technique  and 
after-treatment  have  been  considerably  enlarged,  and  the  portions  devoted  to 
plastic  work  have  been  so  greatly  improved  as  to  be  practically  new.  Hyste- 
rectomy has  been  rewritten,  and  all  the  descriptions  of  operative  procedures 
have  been  carefully  revised   and   fully  illustrated. 


CONTRIBUTORS: 


Dr.  Henry  T.  Byford. 
John  M.  Baldy. 
Edwin  Cragin. 
I.  H.  Etheridge. 
William  Goodell. 


Dr.  Howard  A.  Kelly. 
Florian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor. 
George  M.  Tuttle. 


"  The  most  notable  contribution  to  gynecological  literature  since  1887 and  the  most 

complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have  been  neglected, 
....  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has  any  desire 
to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illustrations 
and  plates  the  book  surpasses  anything  we  have  seen." — Boston  Medical  and  Surgical 
Journal. 

"  A  thoroughly  modern  text-book,  and  gives  reliable  arid  well-tempered  advice  and  in- 
struction."— Edinburgh  Medical  Journal. 

"  The  harmony  of  its  conclusions  and  the  homogeneity  of  its  style  give  it  an  individuality 
which  suggests  a  single  rather  than  a  multiple  authorship." — Annals  of  Surgery. 

"  It  must  command  attention  and  respect  as  a  worthy  representation  of  our  advanced 
clinical  teaching."—  American  Journal  0/  Medical  Sciences. 


CATALOGUE    OF  MEDICAL    WORKS. 


*AN  AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN. By  American  Teachers.  Edited  by  Louis  Starr,  M.  D., 
assisted  by  Thompson  S.  Westcott,  M.  D.  In  one  handsome  royal-8vo 
volume  of  1250  pages,  profusely  illustrated  with  wood-cuts,  half-tone  and 
colored  plates.    Net  Prices:  Cloth,  $7.00;  Sheep  or  Half-Morocco,  $8.00. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  podiatrists,  representing  collectively  the  teachings  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to 
be  a  practical  book,  suitable  for  constant  and  handy  reference  by  the  practi- 
tioner and  the  advanced  student. 

Especial  attention  has  been  given  to  the  latest  accepted  teachings  upon  the 
etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the  disorders  of  chil- 
dren, with  the  introduction  of  many  special  formulae  and  therapeutic  procedures. 

In  this  new  edition  the  whole  subject  matter  has  been  carefully  revised,  new 
articles  added,  some  original  papers  emended,  and  a  number  entirely  rewritten. 
The  new  articles  include  "  Modified  Milk  and  Percentage  Milk-Mixtures," 
"  Lithemia,"  and  a  section  on  "  Orthopedics."  Those  rewritten  are  "  Typhoid 
Fever,"  "Rubella,"  "Chicken-pox,"  "Tuberculous  Meningitis,"  "Hydroceph- 
alus," and  "Scurvy;"  while  extensive  revision  has  been  made  in  "Infant 
Feeding,"  "  Measles,"  "  Diphtheria,"  and  "  Cretinism."  The  volume  has  thus 
been  much  increased  in  size  by  the  introduction  of  fresh  material. 


Dr.  S.  S.  Adams,  Washington. 

John  Ashhurst,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
David  Bovaird,  New  York. 
Dillon  Brown,  New  York. 
Edward  M.  Buckingham,  Boston. 
Charles  W.  Burr,  Philadelphia. 


W.  E.  Casselberry,  Chicago. 
Henry  Dwight  Chapin,  New  York. 

U7     C     /~'U_:„. 1 />l- 


W.  S.  Christopher,  Chicago. 

Archibald  Church,  Chicago. 

Floyd  M.  Crandall,  New  York. 

Andrew  F.  Currier,  New  York. 

Roland  G.  Curtin,  Philadelphia 

J.  M.  DaCos'a,  Philadelphia. 

I.  N.  Danforth,  Chicago. 

Edward  P.  Davis,  Philadelphia. 

John  B.  Deaver,  Philadelphia. 

G.  E.  de  Schweinitz,  Philadelphia. 

John  Doming,  New  York. 

Charles  Warrington  Earle,  Chicago. 

Wm.  A.  Edwards,  San  Diego,  Cal. 

F.  Forchheimer,  Cincinnati. 

J.  Henry  Fruitnight,  New  York. 

J.  P.  Crozer  Griffith,  Philadelphia. 

W.  A.  Hardaway.  St.  Louis. 

M.  P    Hatfield,  Chicago. 

Barton  Cooke  Hirst,  Philadelphia. 

H.  Uloway,  Cincinnati. 

Henry  Jackson,  Boston. 

Charles  G.  Jennings,  Detroit. 

Henry  Koplik.  New  York. 


CONTRIBUTORS : 

Dr.  Thomas  S.  Latimer,  Baltimore. 
Albert  R.  Leeds,  Hoboken,  N.  J. 
J.  Hendrie  Lloyd,  Philadelphia. 
George  Roe  Lockwood,  New  York. 
Henry  M.  Lyman,  Chicago. 
Francis  T.  Miles,  Baltimore. 
Charles  K    Mills,  Philadelphia. 
James  E    Moore,  Minneapolis. 
F.  Gordon  Morrill,  Boston. 


John  H.  Musser,  Philadelphia. 

Thomas  R.  Neilson,  Philadelphia 

W.  P.  Northrup,  New  York. 

William  Osier,  Baltimore. 

Frederick  A.  Packard,  Philadelphia. 

William  Pepper,  Philadelphia. 

Frederick  Peterson,  New  York. 

W.  T.  Plant,  Syracuse,  New  York. 

William  M.  Powell.  Atlantic  City. 

B.  K.  Rachford,  Cincinnati. 

B.  Alexander  Randall,  Philadelphia. 

Edward  O.  Shakespeare,  Philadelphia 

F.  C.  Shattuck,  Boston. 

J.  Lewis  Smith,  New  York. 

Louis  Starr,  Philadelphia. 

M.  Allen  Starr,  New  York. 

Charles  W.  Townsend,  Boston. 

James  Tyson,  Philadelphia. 

W.  S.  Thayer,  Baltimore. 

Victor  C.  Vaughan,  Ann  Arbor,  Mich 

Thompson  S.  Westcott,  Philadelphia. 

Henry  R.  Wharton,  Philadelphia. 

J.  William  White,  Philadelphia. 

J.  C.  Wilson,  Philadelphia. 


12 


IV.   B.   SAUNDERS' 


*  AN  AMERICAN  TEXT-BOOK  OF  GENITO-URINARY  AND 
SKIN  DISEASES.  By  47  Eminent  Specialists  and  Teachers.  Edited 
by  L.  Bolton  Bangs,  M.  D.,  Late  Professor  of  Genito-Urinary  and 
Venereal  Diseases, New  York  Post-Graduate  Medical  School  and  Hospital; 
and  W.  A.  Hardaway,  M.  D.,  Professor  of  Diseases  of  the  Skin,  Mis- 
souri Medical  College.  Imperial  octavo  volume  of  1229  pages,  with  300 
engravings  and  20  full-page  colored  plates.  Cloth,  $7.00  net ;  Sheep  or 
Half-Morocco,  $8.00  net. 

This  addition  to  the  series  of  "  American  Text-Books,"  it  is  confidently  be- 
lieved, will  meet  the  requirements  of  both  students  and  practitioners,  giving,  as 
it  does,  a  comprehensive  and  detailed  presentation  of  the  Diseases  of  the 
Genito-Urinary  Organs,  of  the  Venereal  Diseases,  and  of  the  Affections  of  the 
Skin. 

Having  secured  the  collaboration  of  well-known  authorities  in  the  branches 
represented  in  the  undertaking,  the  editors  have  not  restricted  the  contributors 
ii.  regard  to  the  particular  views  set  forth,  but  have  offered  every  facility  for  the 
free  expression  of  their  individual  opinions.  The  work  will  therefore  be  found 
to  be  original,  yet  homogeneous  and  fully  representative  of  the  several  depart- 
ments of  medical  science  with  which  it  is  concerned. 


CONTRIBUTORS : 


Dr.  Chas.  W.  Allen,  New  York. 
I.  E.  Atkinson,  Baltimore. 
L   Bolton  Bangs,  New  York. 
P.  R.  Bolton,  New  York. 
Lewis  C.  Bosher,  Richmond,  Va. 
John  T.  Bowen,  Boston. 
J.  Abbott  Cantrell.  Philadelphia. 
William  T.  Corlett,  Cleveland,  Ohio. 
B.  Farquhar  Curtis,  New  York. 
Condict  W.  Cutler,  New  York. 
Isadore  Dyer,  New  Orleans. 
Christian   Fenger,  Chicago. 
John  A.  Fordyce,  New  York. 
Eugene  Fuller,  New  York. 
R.  H.  Greene,  New  York. 
Joseph  Grindon,  St.  Louis. 
Graeme  M.  Hammond,  New  York. 
W.  A.  Hardaway,  St.  Louis. 
M.  B.  Hartzeil,  Philadelphia. 
Louis  Heitzmann,  New  York. 
James  S.  Howe,  Boston. 
George  T.  Jackson,  New  York. 
Abraham  Jacobi,  New  York. 
James  C.  Johnston,  New  York. 


Dr.  Hermann  G.  Klotz,  New  York. 
J.  H.  Linsley,  Burlington,  Vt. 
G.  F.  Lydston,  Chicago. 
Hartwell  N.  Lyon,  St.  Louis. 
Edward  Martin,  Philadelphia. 
D.  G.  Montgomery,  San  Francisco. 
James  Pedersen,  New  York. 
S.  Pollitzer,  New  York. 
Thomas  R.  Pooley,  New  York. 
A.  R.  Robinson,  New  York. 
A.  E.  Regensburger,  San  Francisco. 
Francis  J.  Shepherd,  Montreal,  Can. 
S.  C.  Stanton,  Chicago,  111. 
Emmanuel  J.  Stout.  Philadelphia. 
Alonzo  E.  Taylor    Philadelphia. 
Robert  W.  Taylor,  New  York. 
Paul  Thorndike,  Boston. 
H.  Tuholske,  St.  Louis. 
Arthur  Van  Harlingen,  Philadelphia. 
Francis  S.  Watson,  Boston. 
J.  William  White,  Philadelphia. 
J.  McF.  Winfield,  Brooklyn. 
Alfred  C.  Wood,  Philadelphia. 


"This  voluminous  work  is  thoroughly  up  to  date,  and  the  chapters  on  genito-urinary  dis- 
eases are  especially  valuable.  The  illustrations  are  fine  and  are  mostly  original.  Ihe  section 
on  dermatology  is  concise  and  in  every  way  admirable."— Journal  of  the  American  Medical 
Association. 

"This  volume  is  one  of  the  best  yet  issued  of  the  publisher's  series  of  'American  Text- 
Books.'  The  list  of  contributors  represents  an  extraordinary  array  of  talent  and  extended 
experience.  The  book  will  easily  take  the  place  in  comprehensiveness  and  value  of  the 
half  dozen  or  more  costly  works  on  these  subjects  which  have  hitherto  been  necessary  to  a 
well-equipped  library." — New  York  Polyclinic. 


CATALOGUE    OF  MEDICAL    WORKS. 


13 


*  AN  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  THE  EYE, 
EAR,  NOSE,  AND  THROAT.    Edited  by  George  E.  de  Schweinitz, 

A.  M.,  M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical  College;  and 

B.  Alexander  Randall,  A.  M.,  M.  D.,  Clinical  Professor  of  Diseases  of 
the  Ear,  University  of  Pennsylvania.  One  handsome  imperial  octavo 
volume  of  1251  pages;  766  illustrations,  59  of  them  colored.  Prices: 
Cloth,  $7.00  net;  Sheep  or  Half- Morocco,  $8.00  net. 

Just  Issued, 

The  present  work  is  the  only  book  ever  published  embracing  diseases  of  the 
intimately  related  organs  of  the  eye,  ear,  nose,  and  throat.  Its  special  claim 
to  favor  is  based  on  encyclopedic,  authoritative,  and  practical  treatment  of  the 
subjects. 

Each  section  of  the  book  has  been  entrusted  to  an  author  who  is  specially 
identified  with  the  subject  on  which  he  writes,  and  who  therefore  presents  his 
case  in  the  manner  of  an  expert.  Uniformity  is  secured  and  overlapping  pre- 
vented by  careful  editing  and  by  a  system  of  cross-references  which  forms  a 
special  feature  of  the  volume,  enabling  the  reader  to  come  into  touch  with  all 
that  is  said  on  any  subject  in  different  portions  of  the  book. 

Particular  emphasis  is  laid  on  the  most  approved  methods  of  treatment,  so 
that  the  book  shall  be  one  to  which  the  student  and  practitioner  can  refer  for 
information  in  practical  work.  Anatomical  and  physiological  problems,  also, 
are  fully  discussed  for  the  benefit  of  those  who  desire  to  investigate  the  more 
abstruse  problems  of  the  subject. 


CONTRIBUTORS : 


Dr.  Henry  A.  Alderton,  Brooklyn. 
Harrison  Allen,  Philadelphia. 
Frank  All  port,  Chicago. 
Morris  J.  Asch.  New  York. 
S.  C.  Ayres,  Cincinnati. 
R.  O.  Beard,  Minneapolis. 
Clarence  J.  Blake,  Boston. 
Arthur  A    Bliss,  Philadelphia. 
Albert  P.  Brubaker,  Philadelphia. 
J.  H.  Bryan.  Washington,  D.  C. 
Albert  H.  Buck,  New  York. 
F.  Buller,  Montreal,  Can. 
Swan  M.  Burnett,  Washington,  D    C. 
Flemming  Carrow,  Ann  Arbor,  Mich. 
W.  E.  Casselberry,  Chicago. 
Colman  W.  Cutler,  New  York. 
Edward  B.  Dench,  New  York. 
William  S.  Dennett.  New  York. 
George  E.  de  Schweinitz,  Philadelphia. 
Alexander  Duane,  New  York. 
John  \V.  Farlow,  Boston,  Mass. 
Walter  J    Freeman,  Philadelphia. 
H.  Gifford,  Omaha,  Neb. 
W.  C.  Glasgow,  St.  Louis. 
J    Orne  Green,  Boston. 
Ward  A.  Holden,  New  York. 
Christian  R.  Holmes,  Cincinnati. 
William  E.  Hopkins,  San  Francisco. 
F.  C.  Hotz,  Chicago. 
Lucien  Howe,  Buffalo,  N.  Y. 


Dr.  Alvin  A.  Hubbell,  Buffalo,  N.  Y. 
Edward  Jackson,  Philadelphia. 
J.  Ellis  Jennings,  St.  Louis. 
Herman  Knapp,  New  York. 
Chas.  W.  Kollock,  Charleston,  S.  C. 
G.  A.  Leland,  Boston. 
J.  A.  Lippincott,  Pittsburg,  Pa. 
G.  Hudson  Makuen,  Philadelphia. 
John  H.  McCollom,  Boston. 
H.  G.  Miller,  Providence,  R.  I. 
B.  L.  Milliken,  Cleveland,  Ohio. 
Robert  C.  Myles,  New  York. 
James  E.  Newcomb,  New  York. 
R.  J.  Phillips,  Philadelphia. 
George  A.  Piersol,  Philadelphia. 
W.  P.  Porcher,  Charleston.  S.  C. 
B.  Alex.  Randall,  Philadelphia. 
Robert  L.  Randolph,  Baltimore. 
John  O.  Roe,  Rochester,  N.  Y. 
Charles  E.  de  M.  Sajous,  Philadelphia. 
J.  E.  Sheppard.  Brooklyn,  N.  Y. 
E.  L.  Shurly,  Detroit,  Mich. 
William  M.  Sweet,  Philadelphia. 
Samuel  Theobald.  Baltimore,  Md. 
A.  G.  Thomson,  Philadelphia. 
Clarence  A.  Veasey,  Philadelphia. 
John  E.  Weeks,  New  York. 
Casey  A.  Wood,  Chicago,  111. 
Jonathan  Wright,  Brooklyn. 
H.  V.  Würdemann,  Milwaukee,  Wis. 


14 


IV.   B.    SA  VXD E RS' 


*  AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SUR- 
GERY. A  Yearly  Digest  of  Scientific  Progress  and  Authoritative 
Opinion  in  all  branches  of  Medicine  and  Surgery,  drawn  from  journals, 
monographs,  and  text-books  of  the  leading  American  and  Foreign  authors 
and  investigators.  Collected  and  arranged,  with  critical  editorial  com- 
ments, by  eminent  American  specialists  and  teachers,  under  the  general 
editorial  charge  of  George  M.  Gould,  M.D.  One  handsome  imperial 
octavo  volume  of  about  1200  pages.  Uniform  in  style,  size,  and  general 
make-up  with  the  "American  Text-Book"  Series.  Cloth,  36.50  net; 
Half- Morocco,  $7.50  net. 

Now  Ready,  Volumes  for  1896,  1897,  1898,  1899. 

Notwithstanding  the  rapid  multiplication  of  medical  and  surgical  works,  still 
these  publications  fail  to  meet  fully  the  requirements  of  the  general  physician, 
inasmuch  as  he  feels  the  need  of  something  more  than  mere  text-books  of  weil- 
known  principles  of  medical  science. 

This  deficiency  would  best  be  met  by  current  journalistic  literature,  but  most 
practitioners  have  scant  access  to  this  almost  unlimited  source  of  information, 
and  the  busy  practiser  has  but  little  time  to  search  out  in  periodicals  the  many 
interesting  cases  whose  study  would  doubtless  be  of  inestimable  value  in  his 
practice.  Therefore,  a  work  which  places  before  the  physician  in  convenient 
form  an  epitomization  of  this  literature  by  persons  competent  to  pronounce  upon 

The  Value  of  a  Discovery  or  of  a  Method  of  Treatment 

cannot  but  command  his  highest  appreciation.  It  is  this  critical  and  judicial 
function  that  is  assumed  by  the  Editorial  staff  of  the  "  American  Year-Book 
of  Medicine  and  Surgery." 


CONTRIBUTORS 


Dr.  Samuel  "W.  Abbott,  Boston. 
John  J.  Abel,  Baltimore. 
J.  M.  Baldy,  Philadelphia. 
Charles  H.  Burnett,  Philadelphia. 
Archibald  Church,  Chicago. 
J.  Chalmers  DaCosta,  Philadelphia. 
W.  A.  N.  Dorland,  Philadelphia. 
Louis  A.  Duhring,  Philadelphia. 
D.  L.  Edsall,  Philadelphia. 
Virgil  P.  Gibney,  New  York. 
Henry  A.  Griffin,  New  York. 
John  Guiteras,  Philadelphia. 
C.  A.  Hamann,  Cleveland. 
Alfred  Hand,  Jr.,  Philadelphia. 


Dr.  Howard  E.  Hansell,  Philadelphia. 
M.  B.  Hartzeil.  Philadelphia. 
Barton  Cooke  Hirst,  Philadelphia. 
E.  Fletcher  Ingals,  Chicago. 
Wyatt  Johnston,  Montreal. 
W.  W.  Keen,  Philadelphia. 
Henry  G.  Ohls,  Chicago. 
Wendell  Reber,  Philadelphia. 
David  Riesman.  Philadelphia. 
Louis  Starr,  Philadelphia. 
Alfred  Stengel,  Philadelphia. 
G.  N.  Stewart.  Cleveland. 
J.  R.  Tillinghast,  New  York. 
J.  Hilton  Waterman,  New  York. 


"  It  is  difficult  to  know  which  to  admire  most — the  research  and  industry  of  the  distin- 
guished band  of  experts  whom  Dr.  Gould  has  enlisted  in  the  service  of  the  Year- Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  ...  It  is  much  more  than  a  mere  compilation  of  abstracts,  for, 
as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the  advan- 
tage of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers  fully 
qualified  to  perform  these  tasks.  ...  It  is  emphatically  a  book  which  should  find  a  place  in 
every  medical  library,  and  is  in  several  respects  more  useful  than  the  famous  'Jahrbücher.' 
of  Germany." — London  L,ancet. 


CATALOGUE    OF  MEDICAL    WORKS.  1 5 


*  ANOMALIES  AND  CURIOSITIES  OF  MEDICINE.  By  George 
M.  Gould,  M.D.,  and  Walter  L.  Pyle,  M.D.  An  encyclopedic  collec- 
tion of  rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an  ex- 
haustive research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  imperial  octavo 
volume  of  968  pages,  with  295  engravings  in  the  text,  and  12  full-page 
plates.     Gloth,  $6.00  net ;   Half-Morocco,  $7.00  net. 

Several  years  of  exhaustive  research  have  been  spent  by  the  authors  in  the 
great  medical  libraries  of  the  United  States  and  Europe  in  collecting  the  mate- 
rial for  this  work.  Medical  literature  of  all  ages  and  all  languages  has 
been  carefully  searched,  as  a  glance  at  the  Bibliographic  Index  will  show.  The 
facts,  which  will  be  of  extreme  value  to  the  author  and  lecturer,  have  been 
arranged  and  annotated,  and  full  reference  footnotes  given,  indicating  whence 
they  have  been  obtained. 

In  view  of  the  persistent  and  dominant  interest  in  the  anomalous  and  curious, 
a  thorough  and  systematic  collection  of  this  kind  (the  first  of  which  the 
authors  have  knowledge)  must  have  its  own  peculiar  sphere  of  usefulness. 

As  a  complete  and  authoritative  Book  of  Reference  it  will  be  of  value  not 
only  to  members  of  the  medical  profession,  but  to  all  persons  interested  in  gen- 
eral scientific,  sociologic,  and  medico-legal  topics ;  in  fact,  the  general  interest 
of  the  subject  and  the  dearth  of  any  complete  work  upon  it  make  this  volume 
one  of  the  most  important  literary  innovations  of  the  day. 

"One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is,  so  far  as 
we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for  the 
medical  profession  has  this  volume  value  :  it  will  serve  as  a  book  of  reference  for  all  who  are 
interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyn  Medical  Jour- 
nal. 


NERVOUS  AND  MENTAL  DISEASES.  By  Archibald  Church, 
M.  D.,  Professor  of  Clinical  Neurology,  Mental  Diseases,  and  Medical 
Jurisprudence,  Northwestern  University  Medical  School ;  and  Frederick 
Peterson,  M.  D.,  Clinical  Professor  of  Mental  Diseases,  Woman's  Medi- 
cal College,  New  York.  Handsome  octavo  volume  of  843  pages,  with 
over  300  illustrations.  Prices:  Cloth,  $5.00  net;  Half-Morocco,  56.00 
net. 

Just  Issued. 

This  book  is  intended  to  furnish  students  and  practitioners  with  a  practical, 
working  knowledge  of  nervous  and  mental  diseases.  Written  by  men  of  wide 
experience  and  authority,  itwill  present  the  many  recent  additions  to  the  subject. 
The  book  is  not  filled  with  an  extended  dissertation  on  anatomy  and  pathology, 
but,  treating  these  points  in  connection  with  special  conditions,  it  lays  particular 
stress  on  methods  of  examination,  diagnosis,  and  treatment.  In  this  respect  the 
work  will  be  unusually  complete  and  valuable,  laying  down  the  definite  courses 
pf  procedure  which  the  authors  have  found  to  be  most  generally  satisfactory. 


1 6  W.    B.   SAUNDERS' 


A  TEXT-BOOK  OF  PATHOLOGY.  By  Alfred  Stengel,  M.  D., 
Instructor  in  Clinical  Medicine  in  the  University  of  Pennsylvania;  Clinical 
Professor  of  Medicine  in  the  Woman's  Medical  College  of  Pennsylvania; 
Physician  to  the  Philadelphia  Hospital ;  Physician  to  the  Children's  Hos- 
pital, Philadelphia.  Handsome  octavo  volume  of  848  pages,  with  362 
illustrations,  many  of  which  are  in  colors.  Prices:  Cloth,  $4.00  net; 
Half-Morocco,  $5.00  net. 

Just  Issued. 

In  this  work  the  practical  application  of  pathological  facts  to  clinical  medicine 
is  considered  more  fully  than  is  customary  in  works  on  pathology.  While  the 
subject  of  pathology  is  treated  in  the  broadest  way  consistent  with  the  size  of 
the  book,  an  effort  has  been  made  to  present  the  subject  from  the  point  of  view 
of  the  clinician.  The  general  relations  of  bacteriology  to  pathology  are  dis- 
cussed at  considerable  length,  as  the  importance  of  these  branches  deserves.  It 
will  be  found  that  the  recent  knowledge  is  fully  considered,  as  well  as  older  and 
more  widely-known  facts. 

In  the  second  part  of  the  work  the  pathology  of  individual  organs  and  tissues 
is  treated  systematically  and  quite  fully  under  subheadings  that  clearly  indicate 
the  subject-matter  of  each  page. 

The  particular  points  of  the  book  to  be  emphasized  are  the  clear,  concise 
language,  the  convenient  arrangement  of  matter,  the  practical  teaching  value 
of  the  large  collection  of  illustrations,  and  the  modern  and  judicious  treatment 
of  the  entire  subject. 

A  TEXT-BOOK  OF  OBSTETRICS.  By  Barton  Cooke  Hirst,  M.D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome  oc- 
tavo volume  of  846  pages,  with  618  illustrations  and  seven  colored  plates. 
Prices:  Cloth,  $5.00  net;  Half- Morocco,  $6.00  net. 

Just  Issued, 

This  work,  which  has  been  in  course  of  preparation  for  several  years,  is  in- 
tended as  an  ideal  text-book  for  the  student  no  less  than  an  advanced  treatise 
for  the  obstetrician  and  for  general  practitioners.  It  represents  the  very  latest 
teaching  in  the  practice  of  obstetrics  by  a  man  of  extended  experience  and 
recognized  authority.  The  book  emphasizes  especially,  as  a  work  on  obstetrics 
should,  the  practical  side  of  the  subject,  and  to  this  end  presents  an  unusually 
large  collection  of  illustrations.  A  great  number  of  these  are  new  and  original, 
and  the  whole  collection  will  form  a  complete  atlas  of  obstetrical  practice. 
An  extremely  valuable  feature  of  the  book  is  the  large  number  of  refer- 
ences to  cases,  authorities,  sources,  etc.,  forming,  as  it  does,  a  valuable  bib- 
liography of  the  most  recent  and  authoritative  literature  on  the  subject 
of  obstetrics.  As  already  stated,  this  work  records  the  wide  practical  ex- 
perience of  the  author,  which  fact,  combined  with  the  brilliant  presentation 
of  the  subject,  will  doubtless  render  this  one  of  the  most  notable  books  on 
obstetrics  that  has  yet  appeared. 


CATALOGUE    OF  MEDICAL    WORK'S.  I J 

A    TEXT-BOOK     OF    THE    PRACTICE    OF    MEDICINE.      By 

James  M.  Anders,  M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of 
Medicine  and  of  Clinical  Medicine,  Medico-Chirurgical  College,  Philadel- 
phia. In  one  handsome  octavo  volume  of  1 287  pages,  fully  illustrated. 
Cloth,  $5.50  net;  Sheep  or  Half-Morocco,  $6.50  net. 

Second  Edition,     First  Edition  Exhausted  in 
Five  Mont  Us. 

This  work  gives  in  a  comprehensive  manner  the  results  of  the  latest  scientific 
studies  bearing  upon  medical  affections,  and  portrays  with  rare  force  and  clear- 
ness the  clinical  pictures  of  the  different  diseases  considered.  The  practical 
points,  particularly  with  reference  to  diagnosis  and  treatment,  are  completely 
stated  and  are  presented  in  a  most  convenient  form  ;  for  example,  the  differ- 
ential diagnosis  has  in  many  instances  been  tabulated,  no  less  than  fifty-six 
diagnostic  tables  being  given. 

The  first  edition  of  this  work  having  been  exhausted  in  so  short  a  time,  the 
author  has  not  found  it  necessary  to  make  an  extensive  revision,  but  has  simply 
availed  himself  of  the  opportunity  to  make  a  few  changes  of  minor  importance. 

"It  is  an  excellent  book — concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia-to  us." 
—James  C.  Wilson,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine,  Jeffer- 
son Medical  College,  Philadelphia. 

"I  consider  Dr.  Anders'  book  not  only  the  best  late  work  on  Medical  Practice, but  by  far 
the  best  that  has  ever  been  published.  It  is  concise,  systematic,  thorough,  and  fully  up  to 
date  in  everything.  I  consider  it  a  great  credit  to  both  the  author  and  the  publisher." — A. 
C.  Cowperthwaite,  President  of 'ike  Illinois  Homeopathic  Medical  Association. 

DISEASES  OF  THE  STOMACH.  By  William  W.  Van  Vai.zah, 
M.  D.,  Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  York  Polyclinic;  and  J.  Douglas  Nisbet,  M.  D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive  Sys- 
tem and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674  pages, 
illustrated.     Cloth,  $3.50  net. 

An  eminently  practical  book,  intended  as  a  guide  to  the  student,  an  aid  to  the 
physician,  and  a  contribution  to  scientific  medicine.  It  aims  to  give  a  complete 
description  of  the  modern  methods  of  diagnosis  and  treatment  of  diseases  of  the 
stomach,  and  to  reconstruct  the  pathology  of  the  stomach  in  keeping  with  the 
revelations  of  scientific  research.  The  book  is  clear,  practical,  and  complete, 
and  contains  the  results  of  the  authors'  investigations  and  of  their  extensive  ex- 
perience as  specialists.  Particular  attention  is  given  to  the  important  subject  of 
dietetic  treatment.  The  diet-lists  are  very  complete,  and  are  so  arranged  that 
selections  can  readily  be  made  to  suit  individual  cases. 

"This  is  the  most  satisfactory  work  on  the  subject  in  the  English  language." — Chicago 
Medical  Recorder. 

"  The  article  on  diet  and  general  medication  is  one  of  the  most  valuable  in  ihe  book,  and 
should  be  read  by  every  practising  physician." — New  York  Medical  Journal. 


1 8  W.   B.    SAUiYDERS' 


SURGICAL   DIAGNOSIS    AND    TREATMENT.     By   J.  W.   Mac- 
donald,  M.  D.,  Eclin.,  F.  R.  CS.,  Edin.,  Professor  of  the  Practice  of  Sur- 
gery and  of  Clinical  Surgery  in  Hamline  University  ;  Visiting  Surgeon  to  St. 
Barnabas'   Hospital,  Minneapolis,  etc.     Handsome  octavo  volume  of  800 
pages,  profusely  illustrated.     Cloth,  $5.00  net;  Half-Morocco,  $6.00  net. 
This  work  aims  in  a  comprehensive  manner  to  furnish  a  guide  in  matters  of 
surgical  diagnosis.     It  sets  forth  in  a  systematic  way  the  necessities  of  examina- 
tions and  the  proper  methods  of  making  them.     The  various  portions  of  the 
body  are  then  taken  up  in  order  and  the  diseases  and  injuries  thereof  succinctly 
considered  and  the  treatment  briefly  indicated.     Practically  all  the  modern  and 
approved  operations  are  described  with  thoroughness  and  clearness.     The  work 
concludes  with  a  chapter  on  the  use  of  the  Röntgen  rays  in  surgery. 

"  The  work  is  brimful  of  just  the  kind  of  practical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  commend  the  book  because  of  its  intrinsic 
value  to  the  medical  practitioner." — Cincinnati  Lancet-Clinic. 

PATHOLOGICAL  TECHNIQUE.     A  Practical  Manual  for  Laboratory 
Work  in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on 
Post-Mortem  Technique  and  the  Performance  of  Autopsies.     By  Frank 
B.   Mallory,  A.  M.,  M.  D.,  Assistant   Professor  of   Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H.  Wright,  A.  M.,  M.D., 
Instructor  in  Pathology,  Harvard  University  Medical  School,  Boston.     Oc- 
tavo volume  of  396  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 
This  book  is  designed  especially  for  practical  use  in  pathological  laboratories, 
both  as  a  guide  to  beginners  and  as  a  source  of  reference  for  the  advanced.   The 
book  will  also  meet  the  wants  of  practitioners  who  have  opportunity  to  do  general 
pathological  work.     Besides  the  methods  of  post-mortem  examinations  and  of 
bacteriological   and   histological   investigations    connected    with    autopsies,  the 
special   methods   employed  in  clinical  bacteriology  and  pathology  have  been 
fully  discussed. 

"  One  of  the  most  complete  works  on  the  subject,  and  one  which  should  be  in  the  library 
of  every  physician  who  hopes  to  keep  pace  with  the  great  advances  made  in  pathology." — 
Journal  of  American  Medical  Association. 

THE  SURGICAL  COMPLICATIONS  AND  SEQUELS  OF  TY- 
PHOID FEVER.     By  Wm.  W.  Keen,  M.  D.,  LL.D.,  Professor  of  the 
Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College, 
Philadelphia.     Octavo  volume  of  386  pages,  illustrated.     Cloth,  $3.00  net. 
This  monograph  is  the  only  one  in  any  language  covering  the  entire  subject 
of  the  Surgical  Complications  and  Sequels  of  Typhoid  Fever.     The  work  will 
prove  to  be  of  importance  and  interest  not  only  to  the  general  surgeon  and  phy- 
sician, but  also  to  many  specialists — laryngologists,  ophthalmologists,  gynecolo- 
gists, pathologists,  and  bacteriologists — as  the  subject  has  an  important  bearing 
upon  each  one  of  their  spheres.     The  author's  conclusions  are  based  on  reports 
of  over  1700  cases,  including  practically  all  those  recorded  in  the  last  fifty  years. 
Reports  of  cases  have  been  brought  down  to  date,  many  having  been  added 
while  the  work  was  in  press. 

"This  is  probably  the  first  and  only  work  in  the  English  language  that  gives  the  reader  a 
clear  view  of  what  typhoid  fever  really  is,  and  what  it  does  and  can  do  to  the  human  organ- 
ism. This  book  should  be  in  the  possession  of  every  medical  man  in  America." — American 
Medico-Surgical  Bulletin. 


CATALOGUE    OF  MEDICAL    WORKS.  1 9 

MODERN  SURGERY,  GENERAL  AND  OPERATIVE.  By  John 
Chalmers  DaCosta,  M.D.,  Clinical  Professor  of  Surgery,  Jefferson  Medi- 
cal College,  Philadelphia;  Surgeon  to  the  Philadelphia  Hospital,  etc. 
Handsome  octavo  volume  of  911  pages,  profusely  illustrated.  Cloth,  $4.00 
net ;    Half-Morocco,  $5.00  net. 

Second  Edition,  Rewritten  and  Greatly  Enlarged. 

The  remarkable  success  attending  DaCosta's  Manual  of  Surgery,  and  the 
general  favor  with  which  it  has  been  received,  have  led  the  author  in  this 
revision  to  produce  a  complete  treatise  on  modern  surgery  along  the  same  lines 
that  made  the  former  edition  so  successful.  The  book  has  been  entirely  re- 
written and  very  much  enlarged.  The  old  edition  has  long  been  a  favorite  not 
only  with  students  and  teachers,  but  also  with  practising  physicians  and  sur- 
geons, and  it  is  believed  that  the  present  work  will  find  an  even  wider  field  of 
usefulness. 

"We  know  of  no  small  work  on  surgery  in  the  English  language  which  so  well  fulfils  the 
requirements  of  the  modern  student." — Medico-Chirurgical  Journal,  Bristol,  England. 

"  The  author  has  presented  concisely  and  accurately  the  principles  of  modern  surgery. 
The  book  is  a  valuable  one  which  can  be  recommended  to  students  and  is  of  great  value  to 
the  general  practitioner." — American  Journal  of  the  Medical  Sciences. 

A  MANUAL  OF  ORTHOPEDIC  SURGERY.  By  James  E.  Moore, 
M.D.,  Professor  of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume 
of  356  pages,  with  177  beautiful  illustrations  from  photographs  made  spec- 
ially for  this  work.     Cloth,  $2.50  net. 

A  practical  book  based  upon  the  author's  experience,  in  which  special  stress 
is  laid  upon  early  diagnosis  and  treatment  such  as  can  be  carried  out  by  the 
general  practitioner.  The  teachings  of  the  author  are  in  accordance  with  his 
belief  that  true  conservatism  is  to  be  found  in  the  middle  course  between  the 
surgeon  who  operates  too  frequently  and  the  orthopedist  who  seldom  operates. 

"A  very  demonstrative  work,  every  illustration  of  which  conveys  a  lesson.  The  work  is 
a  most  excellent  and  commendable  one,  which  we  can  certainly  endorse  with  pleasure." — 
St.  Louis  Medical  and  Surgical  "Journal. 

ELEMENTARY  BANDAGING  AND  SURGICAL  DRESSING. 
With  Directions  concerning  the  Immediate  Treatment  of  Cases  of  Emer- 
gency. For  the  use  of  Dressers  and  Nurses.  By  Walter  Pye,  F.R.C.S., 
late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo,  with  over  80 
illustrations.     Cloth,  flexible  covers,  75  cents  net. 

This  little  book  is  chiefly  a  condensation  of  those  portions  of  Pye's  "  Surgical 
Handicraft "  which  deal  with  bandaging,  splinting,  etc.,  and  of  those  which 
treat  of  the  management  in  the  first  instance  of  cases  of  emergency.  The 
directions  given  are  thoroughly  practical,  and  the  book  will  prove  extremely  use- 
ful to  students,  surgical  nurses,  and  dressers. 

"The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  portable, 
although  the  paper  and  type  are  good." — British  Medical  Journal. 


20  W.   B.   SAUNDERS' 


A    TEXT-BOOK    OF    MATERIA    MEDICA,    THERAPEUTICS 
AND  PHARMACOLOGY.     By  George  F.  Butler,  Ph.G.,  M.D., 
Professor  of  Materia  Medica  and  of  Clinical  Medicine  in  the  College  of 
Physicians    and    Surgeons,   Chicago;    Professor  of    Materia    Medica    and 
Therapeutics,    Northwestern    University,  Woman's    Medical    School,   etc 
Octavo,  860  pages,  illustrated.     Cloth,  34.00  net ;  Sheep,  $5.00  net. 
Second  Edition,  Thoroughly  Revised. 
A  clear,  concise,  and  practical  text-book,  adapted  for  permanent  reference  no 
less  than  for  the  requirements  of  the  class-room. 

The  recent  important  additions  made  to  our  knowledge  of  the  physiological 
action  of  drugs  are  fully  discussed  in  the  present  edition.  Many  alterations  also 
have  been  made  in  the  chapters  on  Diuretics  and  Cathartics. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory  of  any 
single-volume  works  on  materia  medica  in  the  market."— Journal  of  the  American  Medical 
Association. 

TUBERCULOSIS     OF     THE     GENITO-URINARY     ORGANS, 
MALE  AND  FEMALE.     By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D., 
Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical 
College,   Chicago.     Handsome   octavo  volume   of  320  pages,   illustrated_ 
Cloth,  $3.00  net. 
Tuberculosis   of  the  male  and  female  genito-urinary  organs  is  such  a  frequent, 
distressing,  and  fatal  affection  that  a  special  treatise  on  the  subject  appears  to 
fill  a  gap  in  medical  literature.     In  the  present  work  the  bacteriology  of  the  sub- 
ject has  received  due  attention,  the  modern  resources  employed  in  the  differen- 
tial diagnosis   between  tubercular  and    other  inflammatory  affections   are  fully 
described,  and  the  medical  and  surgical  therapeutics  are  discussed  in  detail. 

"An  important  book  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  important  subjects  of  the  day." — Clinical  Reporter. 

"  A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

A  TEXT-BOOK  OF  DISEASES  OF  WOMEN.  By  Charles  B. 
Penrose,  M.D.,  Ph.D.,  Professor  of  Gynecology  in  the  University  of 
Pennsylvania;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Octavo 
volume  of  529  pages,  with  217  illustrations,  nearly  all  from  drawings  made 
for  this  work.     Cloth,  $3.50  net. 

Second  Edition,  Revised. 
In  this  work,  which  has  been  written  for  both  the  student  of  gynecology  and 
the  general  practitioner,  the  author  presents  the  best  teaching  of  modern  gyne- 
cology untrammelled  by  antiquated  theories  or  methods  of  treatment.  In  most 
instances  but  one  plan  of  treatment  is  recommended,  to  avoid  confusing  the 
student  or  the  physician  who  consults  the  book  for  practical  guidance. 

"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women'  received.  I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." — Howard  A.  Kelly,  Professor 
of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore,  Md. 

"  The  book  is  to  be  commended  without  reserve,  not  only  to  the  student  but  to  the  general 
practitioner  who  wishes  to  have  the  latest  and  best  modes  of  treatment  explained  with  absolute 
clearness." —  Therapeutic  Gazette. 


CATALOGUE    OF  MEDICAL    WORKS.  21 


SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  John 
Collins  Warren,  M.  D.,  LL.D.,  Professor  of  Surgery,  Medical  Depart- 
ment Harvard  University;  Surgeon  to  the  Massachusetts  General  Hospital, 
etc.  A  handsome  octavo  volume  of  832  pages,  with  136  relief  and  litho- 
graphic illustrations,  ^3  of  which  are  printed  in  colors,  and  all  of  which 
were  drawn  by  William  J.  Kaula  from  original  specimens.  Prices  :  Cloth, 
$6.00  net ;  Half-Morocco,  $7.00  net. 

Without  Exception,  the  Illustrations  are  the  Best  ever  Seen  in  a 
Work  of  this  Kind. 

"A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without  ex- 
ception, from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  *  *  *  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their 
coloring  and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the 
barrel  of  a  microscope  at  a  well-mounted  section." — Annals  of  Surgery,  Philadelphia. 

"  It  is  the  handsomest  specimen  of  book-making  *  *  *  that  has  ever  been  issued  from  the 
American  medical  press."—  American  Journal  of  the  Medical  Sciences,  Philadelphia. 

PATHOLOGY  AND  SURGICAL  TREATMENT  OF  TUMORS. 

By  N.  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College ;  Professor  of  Surgery,  Chicago 
Polyclinic ;  Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief, 
St.  Joseph's  Hospital,  Chicago.  One  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  Prices:  Cloth,  $6.00  netj 
Half-Morocco,  $7.00  net. 

Books  specially  devoted  to  this  subject  are  few,  and  in  our  text-books  and 
systems  of  surgery  this  part  of  surgical  pathology  is  usually  condensed  to  a  de- 
gree incompatible  with  its  scientific  and  clinical  importance.  The  author  spent 
many  years  in  collecting  the  material  for  this  work,  and  has  taken  great  pains 
to  present  it  in  a  manner  that  should  prove  useful  as  a  text-book  for  the  student, 
a  work  of  reference  for  the  practitioner,  and  a  reliable  guide  for  the  surgeon. 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  is  handsomely  illustrated  and  printed,  ....  and  the  author  has 
given  a  notable  and  lasting  contribution  to  surgery ." —Journal I  of  American  Medical  Asso- 
ciation, Chicago. 

LECTURES    ON    RENAL    AND    URINARY    DISEASES.      By 

Robert  Saundby,  M.  D.,  Edin.,  Fellow  of  the  Royal  College  of  Physicians, 
London,  and  of  the  Royal  Medico-Chirurgical  Society;  Physician  to  the 
General  Hospital.  Octavo  volume  of  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.     Cloth,  $2.50  net. 

"The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  which  the  views  expressed  are  not  carefully  thought 
out  and  fortified  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended." — British  Medical  Journal. 

"The  work  represents  the  present  knowledge  of  renal  and  urinary  diseases.  It  is  ad- 
mirably written  and  is  accurately  scientific." — Medical  News. 


22  IV.  B.   SAUNDERS' 


A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  John 
M.  Keating,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia ;  Vice-President  of  the  American  Pediatric  Society ;  Ex-President 
of  the  Association  of  Life  Insurance  Medical  Directors;  Editor  "  Cyclo- 
paedia of  the  Diseases  of  Children,"  etc. ;  and  Henry  Hamilton,  author 
of  "A  New  Translation  of  Virgil's  JEneid  into  English  Rhyme;"  co- 
author of  "  Saunders'  Medical  Lexicon,"  etc. ;  with  the  Collaboration  of 
J.  Chalmers  DaCosta,  M.  D.,  and  Frederick  A.  Packard,  M.  D. 
With  an  Appendix  containing  important  Tables  of  Bacilli,  Micrococci, 
Leucomaines,  Ptomaines,  Drugs  and  Materials  used  in  Antiseptic  Sur- 
gery, Poisons  and  their  Antidotes,  Weights  and  Measures,  Thermometric 
Scales,  New  Official  and  Unofficial  Drugs,  etc.  One  very  attractive  volume 
of  over  800  pages.  Second  Revised  Edition.  Prices  :  Cloth,  $5.00  net ; 
Sheep  or  Half-Morocco,  $6.00  net;  with  Denison's  Patent  Ready- Refer- 
ence Index;  without  patent  index,  Cloth,  $4.00  net;  Sheep  or  Half- 
Morocco,  $5.00  net. 

PROFESSIONAL   OPINIONS. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommending 
it  to  my  classes." 

Henky  M.  Lyman,  M.  D.. 
Professor  of  Principles  and  Practice  of  Medicine,  Rush  'Medical  College,  Chicago,  III. 

"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient  in 
size  and  sufficiently  full  for  ordinary  use." 

C.   A.   LlNDSLEY,  M.   D., 

Professor  of  Theory  and  Practice  of  Medicine,  Medical  Dept.  Yale  University: 

Secretary  Connecticut  State  Board  of  Health,  New  Haven,  Conn, 


AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS,  M.  D.,  Emeritus  Pro- 
fessor of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.      Edited  by  his  sons, 
Samuel  W.  Gross,  M.  D.,  LL.D.,  late  Professor  of  Principles  of  Surgery 
and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and  A.  Haller 
Gross,  A.  M.,  of  the  Philadelphia  Bar.     Preceded  by  a  Memoir  of  Dr. 
Gross,  by  the  late  Austin  Flint,  M.  D.,  LL.D.     In  two  handsome  volumeSj 
each  containing  over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine 
Frontispiece  engraved  on  steel.     Price  per  Volume,  #2.50  net. 
This  autobiography,  which  was  continued  by  the  late  eminent  surgeon  until 
within  three  months  of  his  death,  contains  a  full  and  accurate  history  of  his 
early  struggles,  trials,  and  subsequent  successes,  told  in  a  singularly  interesting 
and  charming  manner,  and  embraces  short  and  graphic  pen-portraits  of  many 
of  the  most  distinguished  men — surgeons,  physicians,  divines,  lawyers,  states- 
men, scientists,  etc. — with  whom  he  was  brought  in  contact  in  America  and  in 
Europe  ;  the  whole  forming  a  retrospect  of  more  than  three-quarters  of  a  century. 


CATALOGUE    OF  MEDICAL    WORKS.  23 

PRACTICAL  POINTS  IN  NURSING.  For  Nurses  in  Private 
Practice.  By  Emily  A.  M.  Stoney,  Graduate  of  the  Training-School 
for  Nurses,  Lawrence,  Mass. ;  Superintendent  of  the  Training- School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  handsomely 
illustrated  with  73  engravings  in  the  text,  and  9  colored  and  half-tone 
plates.     Cloth.     Price,  $1.75  net, 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  the  author  explains,  in  popular  language  and  in  the  shortest 
possible  form,  the  entire  range  of  private  nursing  as  distinguished  from  hospital 
nursing,  and  the  nurse  is  instructed  how  best  to  meet  the  various  emergencies  of 
medical  and  surgical  cases  when  distant  from  medical  or  surgical  aid  or  when 
thrown  on  her  own  resources. 

An  especially  valuable  feature  of  the  work  will  be  found  in  the  directions  to 
the  nurse  how  to  improvise  everything  ordinarily  needed  in  the  sick-room,  where 
the  embarrassment  of  the  nurse,  owing  to  the  want  of  proper  appliances,  is  fre- 
quently extreme. 

The  work  has  been  logically  divided  into  the  following  sections : 

I.  The  Nurse:  her  responsibilities,  qualifications,  equipment,  etc. 
II.  The  Sick-Room  :  its  selection,  preparation,  and  management. 

III.  The  Patient :  duties  of  the  nurse  in  medical,  surgical,  obstetric,  and  gyne- 

cologic cases. 

IV.  Nursing  in  Accidents  and  Emergencies. 
V.  Nursing  in  Special  Medical  Cases. 

VI.  Nursing  of  the  New-born  and  Sick  Children. 
VII.  Physiology  and  Descriptive  Anatomy. 

The  Appendix  contains  much  information  in  compact  form  that  will  be  found 
of  great  value  to  the  nurse,  including  Rules  for  Feeding  the  Sick;  Recipes  for 
Invalid  Foods  and  Beverages  ;  Tables  of  Weights  and  Measures ;  Table  for 
Computing  the  Date  of  Labor ;  List  of  Abbreviations ;  Dose-List ;  and  a  full 
and  complete  Glossary  of  Medical  Terms  and  Nursing  Treatment. 

"This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise  and  how  to  prepare  everything  ordinarily 
needed  in  the  illness  of  her  patient." — American  Journal  of  Obstetrics  and  Diseases  of 
Women  and  Children,  Aug.,  1896. 

A  TEXT-BOOK  OF  BACTERIOLOGY,  including  the  Etiology  and 
Prevention  of  Infective  Diseases  and  an  account  of  Yeasts  and  Moulds, 
Haematozoa,  and  Psorosperms.  By  Edgar  M.  Crookshank,  M.  B.,  Pro- 
fessor of  Comparative  Pathology  and  Bacteriology,  King's  College,  London. 
A  handsome  octavo  volume  of  700  pages,  with  273  engravings  in  the  text, 
and  22  original  and  colored  plates.     Price,  $6.50  net. 

This  book,  though  nominally  a  Fourth  Edition  of  Professor  Crookshank's 
"  Manual  of  Bacteriology,"  is  practically  a  new  work,  the  old  one  having 
been  reconstructed,  greatly  enlarged,  revised  throughout,  and  largely  rewritten, 
forming  a  text-book  for  the  Bacteriological  Laboratory,  for  Medical  Officers  of 
Health,  and  for  Veterinary  Inspectors. 


IV.   B.    SAUNDERS 


MEDICAL  DIAGNOSIS.  By  Dr.  Oswald  Vierordt,  Professor  of 
Medicine  at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  Fifth  Enlarged  German  Edition,  with  the  author's  permission,  by 
Francis  H.  Stuart,  A.  M.,  M.  D.  In  one  handsome  royal-octavo  volume 
of  600  pages.  194  tine  wood-cuts  in  the  text,  many  of  them  in  colors. 
Prices:  Cloth,  $4.00  net;  Sheep  or  Half-Morocco,  55.00  net. 

FOURTH  AMERICAN  EDITION,   FROM  THE  FIFTH  REVISED  AND 
ENLARGED  GERMAN  EDITION. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  and  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clin- 
ical work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accu- 
racy. It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over 
without  explanation.  Especial  attention  has  been  given  to  the  gerrn-theory  as  a 
factor  in  the  origin  of  disease. 

The  present  edition  of  this  highly  successful  work  has  been  translated  from 
the  fifth  German  edition.  Many  alterations  have  been  made  throughout  the 
book,  but  especially  in  the  sections  on  Gastric  Digestion  and  the  Nervous  System. 

It  will  be  found  that  all  the  qualities  which  served  to  make  the  earlier  editions 
so  acceptable  have  been  developed  with  the  evolution  of  the  work  to  its  present 
form. 

THE  PICTORIAL  ATLAS  OF  SKIN  DISEASES  AND  SYPHI- 
LITIC AFFECTIONS.  (American  Edition.)  Translation  from 
the  French.  Edited  by  J.  J.  Pringle,  M.  B.,  F.  R.  C.  P.,  Assistant  Phy- 
sician to,  and  Physician  to  the  department  for  Diseases  of  the  Skin  at,  the 
Middlesex  Hospital,  London.  Photo-lithochromes  from  the  famous  models 
of  dermatological  and  syphilitic  cases  in  the  Museum  of  the  Saint-Louis 
Hospital,  Paris,  with  explanatory  wood-cuts  and  letter-press.  In  12  Parts, 
at  $3.00  per  Part. 

"  Of  all  the  atlases  of  skin  diseases  which  have  been  published  in  recent  years,  the  present 
one  promises  to  be  of  greatest  interest  and  value,  especially  from  the  standpoint  of  the 
general  practitioner  " — American  Medico-Surgical  Bulletin,  Feb.  22,  1896. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — New  York  Medical  Journal ',  Feb.  15,  1896. 

"  An  interesting  feature  of  the  Atlas  is  the  descriptive  text,  which  is  written  for  each  picture 
hv  the  physician  who  treated  the  case  or  at  whose  instigation  the  models  have  been  made. 
We  predict  for  this  truly  beautiful  work  a  large  circulation  in  all  parts  of  the  medical  world 
where  the  names  St.  Louis  and  Baretta  have  preceded  it." — Medical  Record,  N.  Y.,  Feb.  1, 
1^96. 

A  TEXT-BOOK  OF  MECHANO-THERAPY  (MASSAGE  AND 
MEDICAL  GYMNASTICS).  By  Axel  V.  Grafstrom,  B.  Sc. 
M.  I).,  late  Lieutenant  in  the  Royal  Swedish  Army;  late  House  Physi- 
cian, City  Hospital,  Blackwell's  Island,  New  York.  i2mo,  139  pages, 
illustrated.     Cloth,  Ä1.00  net. 


CATALOGUE    OF  MEDICAL    WORKS. 


DISEASES  OF  THE  EYE.  A  Hand-Book  of  Ophthalmic  Prac- 
tice. By  G.  E.  DE  Schweinitz,  M.  D.,  Professor  of  Ophthalmology  in 
the  Jefferson  Medical  College,  Philadelphia,  etc.  A  handsome  royal- 
octavo  volume  of  696  pages,  with  255  fine  illustrations,  many  of  which  are 
original,  and  2  chromo-lithographic  plates.  Prices :  Cloth,  #4.00  net ; 
Sheep  or  Half-Morocco,  $5.00  net. 

THIRD  EDITION,  THOROUGHLY  REVISED. 

In  the  third  edition  of  this  text-book,  destined,  it  is  hoped,  to  meet  the  favor- 
able reception  which  has  been  accorded  to  its  predecessors,  the  work  has  been 
revised  thoroughly,  and  much  new  matter  has  been  introduced.  Particular 
attention  has  been  given  to  the  important  relations  which  micro-organisms  bear 
to  many  ocular  diseases.  A  number  of  special  paragraphs  on  new  subjects  have 
been  introduced,  and  certain  articles,  including  a  portion  of  the  chapter  on 
Operations,  have  been  largely  rewritten,  or  at  least  materially  changed.  A 
number  of  new  illustrations  have  been  added.  The  Appendix  contains  a  full 
description  of  the  method  of  determining  the  corneal  astigmatism  with  the 
ophthalmometer  of  Javal  and  Schiötz,  and  the  rotation  of  the  eyes  with  the 
tropometer  of  Stevens. 

"A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.     I  am  satisfied  that  unusual  success  awaits  it." 

William  Pepper,  M    D. 
Provost  and  Professor  0/  Theory  and  Practice  of  Medicine  and  Clinical  Medicine 
in  the  University  of  Pennsylvania. 

"A  clearly  written,  comprehensive  manual.  .  .  .  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering  upon 
the  study  of  this  special  branch  of  medical  science." — British  Medical  Journal. 

"  It  is  hardly  too  much  to  say  that  for  the  student  and  practitioner  beginning  the  study  of 
Ophthalmology,  it  is  the  best  single  volume  at  present  published." — Medical  Neivs. 

"  It  is  a  very  useful,  satisfactory,  and  safe  guide  for  the  student  and  the  practitioner,  and 
one  of  the  best  works  of  this  scope  in  the  English  language." — Annals  of  Ophthalmology. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital,  London  ; 
and  Arthur  E.  Giles,  M.  D.,  B.  Sc,  Lond.,  F.  R.C.  S.,  Edin.,  Assistant 
Surgeon  to  Chelsea  Hospital,  London.  436  pages,  handsomely  illustrated. 
Cloth,  $2.50  net. 

The  authors  have  placed  in  the  hands  of  the  physician  and  student  a  concise 
yet  comprehensive  guide  to  the  study  of  gynecology  in  its  most  modern  develop- 
ment. It  has  been  their  aim  to  relate  facts  and  describe  methods  belonging  to 
the  science  and  art  of  gynecology  in  a  way  that  will  prove  useful  to  students  for 
examination  purposes,  and  which  will  also  enable  the  general  physician  to  prac- 
tice this  important  department  of  surgery  with  advantage  to  his  patients  and  with 
satisfaction  to  himself. 

"  The  book  is  very  well  prepared,  and  is  certain  to  be  well  received  by  the  medical  public." 
—  British  Medical  Journal. 

"  The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  day." — Journal  of  the 
American  Medical  Association. 


2  6  IV.    B    SAUNDERS' 


TEXT-BOOK  UPON  THE  PATHOGENIC  BACTERIA.  Spe- 
cially written  for  Students  of  Medicine.  By  Joseph  McFarland, 
M.  D.,  Professor  of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical 
College  of  Philadelphia,  etc.  497  pages,  finely  illustrated.  Price,  Cloth, 
$2.50  net. 

SECOND  EDITION,  REVISED  AND  GREATLY  ENLARGED. 
The  work  is  intended  to  be  a  text-book  for  the  medical  student  and  for  the 
practitioner  who  has  had  no  recent  laboratory  training  in  this  department  of  medi- 
cal science.  The  instructions  given  as  to  needed  apparatus,  cultures,  stainings, 
microscopic  examinations,  etc.  are  ample  for  the  student's  needs,  and  will  afford 
to  the  physician  much  information  that  will  interest  and  profit  him  relative  to  a 
subject  which  modern  science  shows  to  go  far  in  explaining  the  etiology  of  many 
diseased  conditions. 

In  this  second  edition  the  work  has  been  brought  up  to  date  in  all  depart- 
ments of  the  subject,  and  numerous  additions  have  been  made  to  the  technique 
in  the  endeavor  to  make  the  book  fulfil  the  double  purpose  of  a  systematic  work 
upon  bacteria  and  a  laboratory  guide. 

"  It  is  excellently  adapted  for  the  medical  students  and  practitioners  for  whom  it  is  avowedly 
written.  .  .  .  The  descriptions  given  are  accurate  and  readable,  and  the  book  should  prove 
useful  to  those  for  whom  it  is  written. — London  Laficet,  Aug.  29,  1896. 

"  The  author  has  succeded  admirably  in  presenting  the  essential  details  of  bacteriological 
technics,  together  wiih  a  judiciously  chosen  summary  of  our  present  knowledge  of  pathogenic 
bacteria.  .  .  .  The  work,  we  think,  should  have  a  wide  circulation  among  English-speaking 
students  of  medicine." — N.  Y.  Medical  Journal,  April  4,  1896. 

"The  hook  will  be  found  of  considerable  use  by  medical  men  who  have  not  had  a  special 
bacteriological  training,  and  who  desire  to  understand  this  important  branch  of  medical 
science." — Edinburgh  Medical  Journal,  July,  1896. 

LABORATORY    GUIDE    FOR    THE    BACTERIOLOGIST.      By 

Langdon  Frothingham,  M.  D.  V.,  Assistant  in  Bacteriology  and  Veteri- 
nary Science,  Sheffield  Scientific  School,  Yale  University.  Illustrated. 
Price,  Cloth,  75  cents. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  and 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely  as 
possible.     The  book  is  especially  intended  for  use  in  laboratory  work 

"It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  necessary 
for  its  purchase  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking  up  the 
various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages." — American  Med.- 
Surg.  Bulletin. 

FEEDING    IN    EARLY   INFANCY.     By  Arthur  V.  Meigs,  M.  D 
Bound  in  limp  cloth-  flush  edges.     Price,  25  cents  net. 

Synopsis  :  Analyses  of  Milk— Importance  of  the  Subject  of  Feeding  in  Early 
Infancy — Proportion  of  Casein  and  Sugar  in  Human  Milk — Time  to  Begin  Arti- 
ficial Feeding  of  Infants — Amount  of  Food  to  be  Administered  at  Each  Feed- 
ing— Intervals  between  Feedings — Increase  in  Amount  of  Food  at  Different 
Periods  of  Infant  Development — Unsuitableness  of  Condensed  Milk  as  a  Sub- 
stitute for  Mother's  Milk — Objections  to  Sterilization  or  "Pasteurization"  of 
Milk — Advances  made  in  the  Method  of  Artificial  Feeding  of  Infants. 


CATALOGUE    OF  MEDICAL    WORKS.  2J 

MATERIA    MEDICA    FOR    NURSES.     By  Emily    A.   M.   Stoney, 

Graduate  of  the  Training-school  for  Nurses,  Lawrence,  Mass. ;  late 
Superintendent  of  the  Training-school  for  Nurses,  Carney  Hospital,  South 
Boston,  Mass.     Handsome  octavo,  300  pages.     Cloth,  $1.50  net. 

The  present  book  differs  from  other  similar  works  in  several  features,  all  of 
which  are  introduced  to  render  it  more  practical  and  generally  useful.  The 
general  plan  of  contents  follows  the  lines  laid  down  in  training-schools  for 
nurses,  but  the  book  contains  much  useful  matter  not  usually  included  in  works 
of  this  character,  such  as  Poison-emergencies,  Rendy  Dose-list,  Weights  and 
Measures,  etc.,  as  well  as  a  Glossary,  defining  all  the  terms  in  Materitt  Medica, 
and  describing  all  the  latest  drugs  and  remedies,  which  have  been  generally 
neglected  by  other  books  of  the  kind. 

ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTI- 
CAL DISSECTION,  containing  «  Hints  on  Dissection  "  By  Charles 
B.  Nancrede,  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the 
University  of  Michigan,  Ann  Arbor;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy ;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  lost  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price  :  Extra  Cloth  or  Oilcloth  for  the  dissection-room,  $2.00  net. 

Neither  pains  nor  expense  has  been  spared  to  make  this  work  the  most  ex- 
haustive yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  pub- 
lished, either  in  America  or  in  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscles 
arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been  specially  drawn  anc} 
engraved,  and  an  Appendix  added  containing  60  illustrations  representing  the 
structure  of  the  entire  human  skeleton,  the  whole  being  based  on  the  eleventh 
edition  of  Gray's  Anato?ny, 

A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  Stevens, 
A.  M.,  M.  D.,  Instructor  in  Physical  Diagnosis  in  the  University  of  Penn- 
sylvania, and  Professor  of  Pathology  in  the  Woman's  Medical  College  of 
Pennsylvania.  Specially  intended  for  students  preparing  for  graduation 
and  hospital  examinations.  Post  8vo,  519  pages.  Numerous  illustrations 
and  selected  formulae.     Price,  bound  in  flexible  leather,  $2.00  net. 

FIFTH  EDITION,  REVISED  AND  ENLARGED. 

Contributions  to  the  science  of  medicine  have  poured  in  so  rapidly  during  the 
last  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
limited  time  at  his  disposal,  to  master  elaborate  treatises  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  From  an  extended  experience  in 
teaching,  the  author  has  been  enabled,  by  classification,  to  group  allied  symp- 
toms, and  by  the  judicious  elimination  of  theories  and  redundant  explanations 
to  bring  within  a  comparatively  small  compass  a  complete  outline  of  the  prac- 
tice of  medicine. 


2$  XV.  B.   SAUNDERS 


MANUAL    OF    MATERIA    MEDICA    AND    THERAPEUTICS. 

By  A.  A.  Stevens,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the 
University  of  Pennsylvania,  and  Professor  of  Pathology  in  the  Woman's 
Medical  College  of  Pennsylvania.  445  pages.  Price,  bound  in  flexible 
leather,  S2.25. 

SECOND   EDITION,    REVISED. 

This  wholly  new  volume,  which  is  based  on  the  last  edition  of  the  Pharma- 
copoeia, comprehends  the  following  sections  :  Physiological  Action  of  Drugs ; 
Druas;  Remedial  Measures  other  than  Drugs;  Applied  Therapeutics;  Incom- 
patibility in  Prescriptions;  Table  of  Doses;  Index  of  Drugs;  and  Index  of 
Diseases ;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 

"  The  author  is  to  be  congratulated  upon  having  presented  the  medical  student  with  as 
accurate  a  manual  of  therapeutics  as  it  is  possible  to  prepare."—  Therapeutic  Gazette. 

"  Far  superior  to  most  of  its  class ;  in  fact,  it  is  very  good.  Moreover,  the  book  is  reliable 
and  accurate."—  New  York  Medical  Journal. 

"  The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work,  .  .  . 
and  it  will  be  found  a  reliable  guide."—  University  Medical  Magazine. 

NOTES  ON  THE  NEWER  REMEDIES:  their  Therapeutic  Ap- 
plications and  Modes  of  Administration.  By  David  Cerna,  M.  D., 
Ph.  D.,  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in 
the  University  of  Pennsylvania.     Post-octavo,  253  pages.     Price,  #1.25. 

SECOND  EDITION,  RE-WRITTEN  AND  GREATLY   ENLARGED. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and 
chemical  formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics 
now  in  existence. 

Chemists  are  so  multiplying  compounds,  that,  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  be  carried  far  enough  to  determine  the  prac- 
tical importance  of  the  new  agents. 

"Especially  valuable  because  of  its  completeness,  its  accuracy,  its  systematic  consider- 
ation of  the  properties  and  therapy  of  many  remedies  of  which  doctors  generally  know  but 
little,  expressed  in  a  brief  yet  terse  manner."—  Chicago  Clinical  Review. 


TEMPERATURE   CHART.     Prepared  by   D.  T.  Laine,  M.  D.      Size 
8x13^  inches.     Price,  per  pad  of  25  charts,  50  cents. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Remarks,  etc.  On  the 
back  of  each  chart  is  given  in  full  the  method  of  Brand  in  the  treatment  of 
Typhoid  Fever. 


CATALOGUE    OF  MEDICAL    WORKS.  29 

A  TEXT-BOOK  OF  HISTOLOGY,  DESCRIPTIVE  AND  PRAC- 
TICAL. For  the  Use  of  Students.  By  Arthur  Clarkson,  M.  B., 
C.  M.,  Edin.,  formerly  Demonstrator  of  Physiology  in  the  Owen's  College, 
Manchester;  late  Demonstrator  of  Physiology  in  the  Yorkshire  College, 
Leeds.  Large  8vo,  554  pages,  with  22  engravings  in  the  text,  and  174 
beautifully  colored  original  illustrations.  Price,  strongly  bound  in  Cloth, 
$6.00  net. 

The  purpose  of  the  writer  in  this  work  has  been  to  furnish  the  student  of  His- 
tology, in  one  volume,  with  both  the  descriptive  and  the  practical  part  of  the 
science.  The  first  two  chapters  are  devoted  to  the  consideration  of  the  general 
methods  of  Histology  ;  subsequently,  in  each  chapter,  the  structure  of  the  tissue 
or  organ  is  first  systematically  described,  the  student  is  then  taken  tutorially  over 
the  specimens  illustrating  it,  and,  finally,  an  appendix  affords  a  short  note  of  the 
methods  of  preparation. 

"  The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text-books,  and 
is  to  be  highly  recommended." — New  York  Medical  Journal. 

"  One  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the  book  will 
attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 


THE  PATHOLOGY  AND  TREATMENT  OF  SEXUAL  IM- 
POTENCE. By  Victor  G.  Vecki,  M.  D.  From  the  second  Ger- 
man edition,  revised  and  rewritten.  Demi-octavo,  about  300  pages. 
Cloth,  $2.00  net. 

Just  Issued, 

The  subject  of  impotence  has  but  seldom  been  treated  in  this  country  in  the 
truly  scientific  spirit  that  it  deserves,  and  this  volume  will  come  to  many  as  a 
revelation  of  the  possibilities  of  therapeusis  in  this  important  field.  Dr.  Vecki's 
work  has  long  been  favorably  known,  and  the  German  book  has  received  the 
highest  consideration.  This  edition  is  more  than  a  mere  translation,  for,  although 
based  on  the  German  edition,  it  has  been  entirely  rewritten  by  the  author  in 
English. 

ARCHIVES  OF  CLINICAL  SKIAGRAPHY.  By  Sydney  Rowland, 
B.  A.,  Camb.  A  series  of  collotype  illustrations,  with  descriptive  text, 
illustrating  the  applications  of  the  New  Photography  to  Medicine  and  Sur- 
gery.    Price,  per  Part,  $1.00.      Parts  I.  to  V.  now  ready. 

The  object  of  this  publication  is  to  put  on  record  in  permanent  form  some  of 
the  most  striking  applications  of  the  new  photography  to  the  needs  of  Medicine 
and  Surgery. 

The  progress  of  this  new  art  has  been  so  rapid  that,  although  Prof.  Röntgen's 
discovery  is  only  a  thing  of  yesterday,  it  has  already  taken  its  place  among  the 
approved  and  accepted  aids  to  diagnosis, 


30  W.   B.   SAUNDERS' 


DISEASES    OF    WOMEN.      By    Henry  J.  Garrigues,  A.M.,  M.  D., 

Professor  of  Gynecology  in  the  New  York  School  of  Clinical  Medicine; 
Gynecologist  to  St.  Mark'.-  Hospital  and  to  the  German  Dispensary,  New- 
York  City.  In  one  handsome  octavo  volume  of  728  pages,  illustrated  by 
335  engravings  and  colored  plates.  Prices:  Cloth,  $4.00  net;  Sheep  or 
Half-Morocco,  $5.00  net. 

A  PRACTICAL  work  on  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  know- 
ledge of  the  anatomy  of  the  female  pelvic  organs  has  been  fully  recognized  by 
the  author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chap- 
ters on  Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based 
upon  the  large  hospital  and  private  practice  of  the  author.  The  text  is  eluci- 
dated by  a  large  number  of  illustrations  and  colored  plates,  many  of  them  being 
original,  and  forming  a  complete  atlas  for  studying  embryology  and  the  anatomy 
of  the  female  genitalia,  besides  exemplifying,  whenever  needed,  morbid  condi- 
tions, instruments,  apparatus,  and  operations. 

Second  Edition,  Thoroughly  Revised. 

The  first  edition  of  this  work  met  with  a  most  appreciative  reception  by  the 
medical  press  and  profession  both  in  this  country  and  abroad,  and  was  adopted 
as  a  text-book  or  recommended  as  a  book  of  reference  by  nearly  one  hundred 
colleges  in  the  United  States  and  Canada.  The  author  has  availed  himself  of 
the  opportunity  afforded  by  this  revision  to  embody  che  latest  approved  advances 
in  the  treatment  employed  in  this  important  branch  of  Medicine.  He  has  also 
more  extensively  expressed  his  own  opinion  on  the  comparative  value  of  the 
different  methods  of  treatment  employed. 

"One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners,  to  whom  experienced  consultants 
may  not  be  available,  will  find  in  this  book  invaluable  counsel  and  help." 

Thad.  A.  Reamy,  M.  D.,  LL.D., 
Professor  of  Clinical  Gynecology ,  Medical  College  of  Ohio  ;   Gynecologist  to  the  Good 
Samaritan  and  Cincinnati  Hospitals. 


\  SYLLABUS  OF*  GYNECOLOGY,  arranged  in  conformity  with 
"An  American  Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.     Price,  Cloth  (interleaved),  $1.00  net. 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work,  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  who  do  not  already 
possess  the  text-book  it  will  also  have  an  independent  value  as  an  aid  to  the 
practitioner  in  gynecological  work,  and  to  the  student  as  a  guide  in  the  lecture- 
room,  as  the  subject  is  1  resented  in  a  manner  at  once  systematic,  clear,  succinct, 
?cd  practical. 


CATALOGUE    OF  MEDICAL    WORKS.  3 1 

THE  AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited 
by  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital 
of  the  University  of  Pennsylvania;  Fellow  of  the  American  Academy  of 
Medicine.  Containing  the  pronunciation  and  definition  of  over  26,000 
words  used  in  medicine  and  the  kindred  sciences,  with  64  extensive  tables. 
Handsomely  bound  in  flexible  leather,  limp,  with  gold  edges.  Price, 
$1.25  net. 

Over  26,000   Words,  64   Valuable  Tables. 

This  is  the  ideal  pocket  lexicon.  It  is  an  absolutely  new  book,  and  not  a  re- 
vision of  any  old  work.  It  is  complete,  defining  all  the  terms  of  modern  medi- 
cine and  forming  a  vocabulary  of  over  26,000  words.  It  gives  the  pronunciation 
of  all  the  terms.  It  makes  a  special  feature  of  the  newer  words  neglected  by 
other  dictionaries.  It  contains  a  wealth  of  anatomical  tables  of  special  value  to 
students.     It  forms  a  handy  volume,  indispensable  to  every  medical  man. 

SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  William 
M.  Powell,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1800  Formulae,  selected  from  several 
hundred  of  the  best  known  authorities.  Forming  a  handsome  and  con- 
venient pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves 
for  Additions;  with  an  Appendix  containing  Posological  Table,  Formulae 
and  Doses  for  Hypodermatic  Medication,  Poisons  and  their  Antidotes, 
Diameters  of  the  Pemale  Pelvis  and  Fcetal  Head,  Obstetrical  Table,  Diet 
List  for  Various  Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery, 
Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables 
of  Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  morocco,  with  side  index,  wallet,  and  flap.  Price,  $1.75 
net. 

FIFTH  EDITION,  THOROUGHLY  REVISED. 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and  as  the  name  of  the  author  of  each  prescription  is 
given, is  unusually  reliable." — New  York  Medical  Record. 

A  COMPENDIUM  OF  INSANITY.  By  John  B.  Chapin,  M.D.,  LL.D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane;  late  Physician- 
Superintendent  of'the  Willard  State  Hospital,  New  York;  Honorary  Mem- 
ber of  the  Medico-Psychological  Society  of  Great  Britain,  of  the  Society  of 
Mental  Medicine  of  Belgium.      121110,  234  pages,  illust.     Cloth,  $1.25  net. 

The  author  has  given,  in  a  condensed  and  concise  form,  a  compendium  of 
Diseases  of  the  Mind,  for  the  convenient  use  and  aid  of  physicians  and  students. 
It  contains  a  clear,  concise  statement  of  the  clinical  aspects  of  the  various  ab- 
normal mental  conditions,  with  directions  as  to  the  most  approved  methods  of 
managing  and  treating  the  insane. 

"  The  practical  parts  of  Dr.  Chapin's  book  are  what  constitute  its  distinctive  merit.  \Ve 
desire  especially,  however,  to  call  attention  to  the  fact  that  in  the  subject  of  the  therapeutics 
of  insanity  the  work  is  exceedingly  valuable.  The  author  has  made  a  distinct  addition  to  the 
literature  of  his  specialty." — Philadelphia  Medical  Journal. 


32  W.   B.    SAUNDERS' 


AN  OPERATION  BLANK,  with  Lists  of  Instruments,  etc.  re- 
quired in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.  D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  Col- 
lege, Philadelphia.  Price  per  Pad,  containing  Blanks  for  fifty  operations, 
50  cents  net. 

SECOND  EDITION,  REVISED  FORM. 

A  convenient  blank,  suitable  for  all  operations,  giving  complete  instructions 
regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

On  the  back  of  each  blank  is  a  list  of  instruments  used  — viz.  general  instru 
ments,  etc.,  required  for  all  operations ;  and  special  instruments  for  surgery  of 
the  brain  and  spine,  mouth  and  throat,  abdomen,  rectum,  male  and  female 
genito-urinary  organs,  the  bones,  etc. 

The  whole  forming  a  neat  pad,  arranged  for  hanging  on  the  wall  of  a  sur- 
geon's office  or  in  the  hospital  operating-room. 

"  Will  serve  a  useful  purpose  fur  the  surgeon  in  reminding  him  of  the  details  of  prepa- 
ration for  the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics 
needed  " — Xew  York  Medical  Record 

"  Covers  about  all  that  can  be  needed  in  any  operation." — American  Lancet. 

"  The  plan  is  a  capital  one." —Boston  Medical  and  Surgical  Journal. 

LABORATORY  EXERCISES  IN  BOTANY.  By  Edson  S.  Bastin, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Pharmacy.  Octavo  volume  of  536  pages,  87  full-page  plates.  Price, 
Cloth,  $2.50. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  Illustra- 
tions have  freely  been  used  to  elucidate  the  text,  and  a  complete  index  to  facil- 
itate reference  has  been  added. 

"  There  is  no  work  like  it  in  the  pharmaceutical  or  botanical  literature  of  this  country,  and 
we  predict  for  it  a  wide  circulation." — American  Journal  of  Pharmacy. 

DIET  IN  SICKNESS  AND  IN  HEALTH.  By  Mrs.  Ernest  Hart, 
formerly  Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London 
School  of  Medicine  for  Women  ;  with  an  INTRODUCTION  by  Sir  Henry 
Thompson,  F.  R.  C.  S.,  M.  D.,  London.  220  pages;  illustrated.  Price, 
Cloth,  $1.50. 

Useful  to  those  who  have  to  nurse,  feed,  and  prescribe  for  the  sick.  In 
each  case  the  accepted  causation  of  the  disease  and  the  reasons  for  the  special 
diet  prescribed  are  briefly  described.  Medical  men  will  find  the  dietaries  and 
recipes  practically  useful,  and  likely  to  save  them  trouble  in  directing  the  dietetic 
treatment  of  patients. 


CATALOGUE    OF  MEDICAL    WORKS.  33 

A  MANUAL  OF  PHYSIOLOGY,  with  Practical  Exercises.  For 
Students  and  Practitioners.  By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc, 
lately  Examiner  in  Physiology,  University  of  Aberdeen,  and  of  the  New 
Museums,  Cambridge  University ;  Professor  of  Physiology  in  the  Western 
Reserve  University,  Cleveland,  Ohio.  Handsome  octavo  volume  of  848 
pages,  with  300  illustrations  in  the  text,  and  5  colored  plates.    Price,  Cloth, 

$3-75  net- 

THIRD  EDITION,  REVISED. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.  It  is  o?ie  oj 
the  very  best  English  text-books  on  the  subject." — London  Lancet. 

"  Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so  nearly 
comes  up  to  the  ideal  as  does  Professor  Stewart's  volume." — British  Medical  Journal. 

ESSENTIALS  OF  PHYSICAL  DIAGNOSIS  OF  THE  THORAX. 

By  Arthur  M.  Corwin,  A.  M.,  M.  D.,  Demonstrator  of  Physical  Diagno- 
sis in  the  Rush  Medical  College,  Chicago;  Attending  Physician  to  the 
Central  Free  Dispensary,  Department  of  Rhinology,  Laryngology,  and 
Diseases  of  the  Chest.  200  pages.  Illustrated.  Cloth,  flexible  covers. 
Price,  $1.25  net. 

SYLLABUS  OF  OBSTETRICAL  LECTURES  in  the  Medical 
Department,  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.  M.,  M.  D.,  Lecturer  on  Clinical  and  Operative  Obstetrics,  University 
of  Pennsylvania.  Third  edition,  thoroughly  revised  and  enlarged.  Crown 
8vo.     Price,  Cloth,  interleaved  for  notes,  $2.00  net. 

"  This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in  call- 
ing attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner.  The  author  has  introduced  a 
number  of  valuable  hints  which  would  only  occur  to  one  who  was  himself  an  experienced 
teacher  of  obstetrics.  The  subject-matter  is  clear,  forcible,  and  modern.  We  are  especially 
pleased  with  the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of  the  child, 
etc.  The  paragraphs  on  antiseptics  are  admirable;  there  is  no  doubtful  tone  in  the  direc- 
tions given.  No  details  are  regarded  as  unimportant ;  no  minor  matters  omitted.  We  ven- 
ture to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which  he  can- 
not afford  to  despise." — New  York  Medical  Record. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  "  An  American  Text-Book 
of  Surgery."  By  N.  Senn,  M.  D.,  Ph.  D.,  Professor  of  Surgery  in  Rusr 
Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.     Price,  $2.00. 

This  work  by  so  eminent  an  author,  himself  one  of  the  contributors  to 
"  An  American  Text- Book  of  Surgery,"  will  prove  of  exceptional  value  to 
the  advanced  student  who  has  adopted  that  work  as  his  text-book.  _  It  is  not 
only  the  syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an 
epitome  of  or  supplement  to  the  larger  work. 

"  The  author  has  evidently  spared  no  pains  in  making  his  Syllabus  thoroughly  comprehen- 
sive, and  has  added  new  matter  and  alluded  to  the  most  recent  authors  and  operations.  Full 
references  are  also  given  to  all  requisite  details  of  surgical  anatomy  and  pathology." — British 
Medical  Journal,  London. 


34  W.   B.   SAUNDERS' 


THE  CARE  OF  THE  BABY.  By  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  404  pages,  with 
67  illustrations  in  the  text,  and  5  plates.      i2mo.     Price,  $1.50. 

SECOND  EDITION,  REVISED. 

A  reliable  guide  not  only  for  mothers,  but  also  for  medical  students  and 
practitioners  whose  opportunities  for  observing  children  have  been  limited. 

"  The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a  mas- 
ter hand.  It  can  be  read  with  benefit  not  only  by  mothers,  but  by  medical  students  and  by 
any  practitioners  who  have  not  had  large  opportunities  for  observing  children." — American 
f,  u  mal  of  Obstetrics. 

THE  NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing 
Treatment,  containing  Definitions  of  the  Principal  Medical  and  Nurskig 
Terms,  Abbreviations,  and  Physiological  Names,  and  Descriptions  of  the 
Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations,  Foods, 
Appliances,  etc.  encountered  in  the  ward  or  the  sick-room.  By  Honnor 
Morten,  author  of  "  How  to  Become  a  Nurse,"  "  Sketches  of  Hospital 
Life,"  etc.      i6mo,  140  pages.     Price,  Cloth,  #1.00. 

This  little  volume  is  intended  for  use  merely  as  a  small  reference-book  which 
can  be  consulted  at  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation 
to  the  nurse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look  up 
larger  and  fuller  works  on  the  subject. 

DIET  LISTS  AND  SICK-ROOM  DIETARY.  By  Jerome  B.  Thomas, 
M.  D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital ;  Assistant  Bacteriologist,  Brooklyn  Health  Department. 
Price,  Cloth,  $1.50    (Send  for  specimen  List.) 

One  hundred  and  sixty  detachable  (perforated)  diet  lists  for  Albuminuria, 
Anaemia  and  Debility,  Constipation,  Diabetes,  Diarrhoea,  Dyspepsia,  Fevers, 
Gout  or  Uric- Acid  Diathesis,  Obesity,  and  Tuberculosis.  Also  forty  detachable 
sheets  of  Sick-Room  Dietary,  containing  full  instructions  for  preparation  of 
easily-digested  foods  necessary  for  invalids.  Each  list  is  numbered  only,  the 
disease  for  which  it  is  to  be  used  in  no  case  being  mentioned,  an  index  key 
being  reserved  for  the  physician's  private  use. 

DIETS  FOR  INFANTS  AND  CHILDREN  IN  HEALTH  AND 
IN  DISEASE.  By  Louis  Starr,  M.  D.,  Editor  of  "An  American 
Text-Book  of  the  Diseases  of  Children."  230  blanks  (pocket-book  size), 
perforated  and  neatly  bound  in  flexible  morocco.     Price,  #1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant 
life;  each  blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food, 
the  latter  directions  being  left  for  the  physician.  After  the  seventh  month, 
modifications  being  less  necessary,  the  diet  lists  are  printed  in  full.  Formula 
fo*   ine  preparation  of  diluents  and  foods  are  appended. 


CATALOGUE   OF  MEDICAL    WORKS.  35 


HOW  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  John  M. 
Keating,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of 
Philadelphia;  Vice-President  of  the  American  Pediatric  Society;  Ex- 
President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal 
8vo,  211  pages,  with  two  large  half-tone  illustrations,  and  a  plate  prepared 
by  Dr.  McClellan  from  special  dissections;  also,  numerous  cuts  to  elucidate 
the  text.     Third  edition.      Price,  Cloth,  $2.00  net. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination,  a 
subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume  is 
Part  II.,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected 
by  the  directors  of  the  companies,  they  form  the  latest  instructions  obtainable.  If  for  these 
alone,  the  book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special  branch 
of  medical  science." — The  Medical  Nezus,  Philadelphia. 

NURSING:  ITS  PRINCIPLES  AND  PRACTICE.  By  Isabel 
Adams  Hampton,  Graduate  of  the  New  York  Training  School  for 
Nurses  attached  to  Bellevue  Hospital;  Superintendent  of  Nurses  and 
Principal  of  the  Training  School  for  Nurses,  Johns  Hopkins  Hospital, 
Baltimore,  Md. ;  late  Superintendent  of  Nurses,  Illinois  Training  School 
for  Nurses,  Chicago,  111.  In  one  very  handsome  i2mo  volume  of  512 
pages,  illustrated.     Price,   Cloth,  $2.00   net. 

SECOND   EDITION,  REVISED  AND  ENLARGED. 

This  original  work  on  the  important  subject  of  nursing  is  at  once  comprehensive 
and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable  style,  suitable 
alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long  been  a  desidera- 
tum with  those  entrusted  with  the  management  of  hospitals  and  the  instruction  of 
nurses  in  training-schools.  It  is  also  of  especial  value  to  the  graduated  nurse 
who  desires  to  acquire  a  practical  working  knowledge  of  the  care  of  the  sL.; 
and  the  hygiene  of  the  sick-room. 

OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND  OPERA- 
TIONS. By  L.  Ch.  Boisliniere,  M.  D.,  late  Emeritus  Professor  of 
Obstetrics  in  the  St.  Louis  Medical  College.  381  pages,  handsomely  illus- 
trated.    Price,  $2.00  net. 

"  For  the  use  of  the  practitioner  who,  when  away  from  home,  has  not  the 
opportunity  of  consulting  a  library  or  of  calling  a  friend  in  consultation.  He 
then,  being  thrown  upon  his  own  resources,  will  find  this  book  of  benefit  in 
guiding  and  assisting  him  in  emergencies." 

INFANT'S  WEIGHT  CHART.  Designed  by  J.  P.  Crozer  Griffith, 
M.  D.,  Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Penrt 
sylvania.    25  charts  in  each  pad.     Price  per  pad,  50  cents  net. 

A  convenient  blank  for  keeping  a  record  of  the  child's  weight  during  the  first 
two  years  of  life.  Printed  on  each  chart  is  a  curve  representing  the  average  weight 
of  a  healthy  infant,  so  that  any  deviation  from  the  normal  can  readily  be  detected. 


Saunders? 
New  Series 
of  Manuals 


for  Students 
and 
Practitioners. 


'T'HAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading 
■*•  branches  of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the 
favor  with  which  the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been 
received  by  medical  students  and  practitioners  and  by  the  Medical  Press. 
These  manuals  are  not  merely  condensations  from  present  literature,  but 
are  ably  written  by  well-known  authors  and  practitioners,  most  of  them  being 
teachers  in  representative  American  colleges.  Each  volume  is  concisely  and 
authoritatively  written  and  exhaustive  in  detail,  without  being  encumbered 
with  the  introduction  of  "  cases,"  which  so  largely  expand  the  ordinary  text- 
book. These  manuals  will  therefore  form  an  admirable  collection  of  advanced 
lectures,  useful  alike  to  the  medical  student  and  the  practitioner :  to  the  latter, 
too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  what  he 
wants  to  know,  they  will  prove  of  inestimable  value  ;  to  the  former  they  will 
afford  safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be 
superior  to  any  similar  books  now  on  the  market.  No  other  manuals  afford  so 
much  information  in  such  a  concise  and  available  form.  A  liberal  expenditure 
has  enabled  the  publisher  to  render  the  mechanical  portion  of  the  work  worthy 
of  the  high  literary  standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page 
lor  List). 


SAUNDERS'  NEW  SERIES  OF  MANUALS. 


VOLUMES  PUBLISHED. 


PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.  M.,  M.  D.,  Professor 
of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long 
Island  College  Hospital,  etc.     Price,  $1.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta, 
M.  D.,  Professor  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadel- 
phia. Second  edition,  revised  and  greatly  enlarged.  Octavo,  911  pages, 
386  illustrations.     Cloth,  $4.00  net ;   Half-Morocco,  $5.00  net. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION- WRITING. 
By  E.  Q.  Thornton,  M.  D.,  Demonstrator  of  Therapeutics,  Jefferson 
Medical  College,  Philadelphia.     Price,  $1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.  D.,  Pro- 
fessor of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jeffer- 
son Medical  College  of  Philadelphia,  etc,     Price,  $1.50  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  German  Poliklinik ;  Instructor  in  Surgery,  New  York 
Post-Graduate  Medical  School,  etc.     Price,  #1.25  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department 
of  the  New  York  University,  etc.     Price,  $2.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James 
Nevins  Hyde,  M.  D.,  Professor  of  Skin  and  Venereal  Diseases,  and 
Frank  H.  Montgomery,  M.  D.,  Lecturer  on  Dermatology  and  Genito- 
urinary Diseases  in  Rush  Medical  College,  Chicago.     Price,  $2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.  D., 
Professor  of  Practice  in  the  Woman's  Medical  College  of  the  New  York 
Infirmary,  etc.     Price,  $2.50  net. 

OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Demon- 
strator of  Obstetrics,  University  of  Pennsylvania ;  Chief  of  Gynecological 
Dispensary,  Pennsylvania  Hospital.     Price,  $2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant 
Surgeon  to  the  Middlesex  Hospital,  and  Surgeon  to  the  Chelsea  Hospital 
for' Women,  London ;  and  Arthur  E.  Giles,  M.  D.,  B.  Sc.  Lond.,  F.  R.  C.  S. 
Edin.,  Assistant  Surgeon  to  the  Chelsea  Hospital  for  Women,  London.  436 
pages,  handsomely  illustrated.     Price,  $2.50  net. 

IN    PREPARATION. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.  D.,  Clinical  Profes- 
sor of  Nervous  Diseases,  Medico-Chirurgical  College,  Philadelphia,  etc. 

***  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully  prepared  works 
on  various  subjects,  by  prominent  specialists. 

37 


SAUNDERS'  QUESTION  COMPENDS. 

Arranged  in  Question  and  Answer  Form, 

THE  LATEST,  MOST  COMPLETE,  and  BEST  ILLUSTRATED 
SERIES  OF  COMPENDS  EVER  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature 


Students  and  Practitioners  in  every  City  of  the  United 
States  and  Canada. 


THE    REASON    WHY. 

They  are  the  advance  guard  of  "  Student's  Helps  " — that  do  help;  they  are 
the  leaders  in  their  special  line,  well  and  authoritatively  written  by  able  men, 
who,  as  teachers  in  the  large  colleges,  know  exactly  what  is  wanted  by  a  student 
preparing  for  his  examinations.  The  judgment  exercised  in  the  selection  of 
authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen  from  the 
ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of  them  have  be- 
come Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250 
pages,  profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on 
fine  paper. 

The  entire  series,  numbering  twenty- four  subjects,  has  been  kept  thoroughly 
revised  and  enlarged  when  necessary,  many  of  them  being  in  their  fourth  and 
fifth  editions. 

TO   SUM    UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  mar- 
ket, none  of  them  approach  the  "  Blue  Series  of  Question  Compends;"  and 
the  claim  is  made  for  the  following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Size  of  type  and  quality  of  paper  and  binding. 

Any  of  these  Compends  will  be  mailed  on  receipt  of  price  (see  next 

page  for  List). 

38 


SAUNDERS'  QUESTION.COMPEND  SERIES. 

Price,  Cloth,  $J,00  per  copy,  except  when  otherwise  noted. 


1.  ESSENTIALS  OF  PHYSIOLOGY.    4th  edition.    Illustrated.    Revised  and  enlarged. 

By  H.  A.  Hare,  M.  D.     (Price,  $1.00  net.) 

2.  ESSENTIALS  OF  SURGERY.     6th  edition,  with  an  Appendix  on  Antiseptic  Sur- 

gery.    90  illustrations.     By  Edward  Martin,  M.  D. 

3.  ESSENTIALS  OF    ANATOMY.     5th  edition,  with  an  Appendix.     180  illustrations. 

By  Charles  B.  Nancrede,  M.  D. 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

4th  edition,  revised,  with  an  Appendix.     By  Lawrence  Wolff,  M.  D. 

5.  ESSENTIALS  OF  OBSTETRICS.     4th  edition,  revised  and  enlarged.      75  illustra- 

tions.    By  W.  Easterly  Ashton,  M.  D. 

6.  ESSENTIALS  OF  PATHOLOGY   AND  MORBID  ANATOMY.     7th  thousand. 

46  illustrations.     By  C.  E.  Armand  Semple,  M.  D. 

7.  ESSENTIALS    OF    MATERIA      MEDICA,     THERAPEUTICS,    AND    PRE- 

SCRIPTION-WRITING.     5th  edition.      By  Henry  Morris,  M.  D. 

8,9.  ESSENTIALS  OF  PRACTICE  OF  MEDICINE.  By  Henry  Morris,  M.  D. 
An  Appendix  on  Urine  Examin  ation.  Illustrated.  By  Lawrence  Wolff,  M.  D. 
3d  editiQn,  enlarged  by  some  300  Essential  Formulas,  selected  from  eminent  authori- 
ties, by  Wm.  M.  Powell,  M.  D.     (Double  number,  price  $2.00.) 

10.  ESSENTIALS  OF  GYNAECOLOGY.     4th  edition,  revised.     With  62  illustrations. 

By  Edwin  B.  Cragin,  M.  D. 

11.  ESSENTIALS  OF  DISEASES  OF    THE  SKIN.    3d  edition,  revised  and  enlarged. 

71  letter-press  cuts  and  15  half-tone  illustrations.    By  Henry  W.  Stelwagon,  M.D. 
(Price,  $1.00  net.) 

12.  ESSENTIALS  OF  MINOR    SURGERY,   BANDAGING,  AND  VENEREAL 

DISEASES.     2d    edition,   revised    and    enlarged.     78   illustrations.      By  Edward 
Martin,  M.  D. 

13.  ESSENTIALS  OF  LEGAL     MEDICINE,   TOXICOLOGY,  AND    HYGIENE. 

130  illustrations.     By  C.  E.   Armand  Semple,  M.  D. 

14.  ESSENTIALS  OF  DISEASES  OF   THE  EYE,  NOSE,  AND  THROAT.    124 

illustrations.     2d  edition,  revised.      By  Edward  Jackson,  M.  D.,  and  E.  Baldwin 
Gleason,  M.  D. 

15.  ESSENTIALS  OF    DISEASES  OF  CHILDREN.     2d  edition.     By  William  M. 

Powell,  M.  D. 

16.  ESSENTIALS  OF  EXAMINATION    OF    URINE.      Colored   "  Vogel  Scale," 

and  numerous  illustrations.      By   Lawrence  Wolff,  M.  D.     (Price,  75  cents.) 

17.  ESSENTIALS  OF    DIAGNOSIS.     5s    illustrations,  some  in   colors.     By  S.  Solis- 

Cohen,  M.  D.,  and  A.  A.  Eshner,  M.  D.     (Price,  $1.50  net.) 

18.  ESSENTIALS  OF   PRACTICE  OF  PHARMACY.     2d   edition,  revised.     By  L. 

E.  Sayre. 

20.  ESSENTIALS  OF   BACTERIOLOGY.      3d   edition.     82   illustrations.     By  M.  V. 

Ball,  M.D. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.    48  illustrations. 

3d  edition,  revised.     By  John  C.  Shaw,  M.  D. 

22.  ESSENTIALS  OF  MEDICAL  PHYSICS.     155  illustrations.      2d  edition,  revised. 

By  Fred  J.  Brockway,  M.  D.     (Price,  $1.00  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.     65  illustrations.     By  David  D. 

Stewart,  M.  D.,  and  Edward  S.  Lawrance,  M.  D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE  EAR.     114  illustrations.    2d  edition,  re- 

vised and  enlarged.     By  E.  Baldwin  Gleason,  M.  D. 


IN   PREPARATION. 

THE  INTERNATIONAL  TEXT=BOOK  OF  SURGERY.     In  two  volumes. 

By  American  and  British  authors.  .Edited  by  J.  Collins  Warren,  M.  D.,  LL.D.,  Pro- 
fessor of  Surgery,  Harvard  Medical  School,  Boston ;  Surgeon  to  the  Massachusetts 
General  Hospital;  and  A.  Pearce  Gould,  M.S.,  F.  R.C.S.,  England,  Lecturer  or. 
Practical  Surgery  and  Teacher  of  Operative  Surgery,  Middlesex  Hospital  Medical 
School;  Surgeon  to  .the  Middlesex   Hospital,  London,  England. 

AN  AMERICAN  TEXT=BOOK  OF  PATHOLOGY. 

Edited  by  John  Guiteras,  M.D.,  Professor  of  General  Pathology  and  of  Morbid 
Anatomy,  University  of  Pennsylvania  ;  and  David  Riesman,  M.  D.,  Demonstrator  of 
Pathological  Histology,  University  of  Pennsylvania. 

AN  AMERICAN  TEXT=BOOK  OF  LEGAL  MEDICINE  AND  TOXICOLOGY. 

Edited  by  Frederick  Peterson,  M.  D.,  Clinical  Professor  of  Mental  Diseases, 
Woman's  Medical  College,  New  York;  and  Walter  S.  Haines,  M.  D.,  Professor 
of  Chemistry,  Pharmacy,  and  Toxicology,  Rush  Medical  College,  Chicago. 

AN  AMERICAN  TEXT=BOOK  OF  DIAGNOSIS. 

Edited  by  Alfred  Stengel.  M.  D.,  Physician  to  the  Philadelphia  Hospital;  Professor 
of  Clinical  Medicine  in  the  Woman's  Medical  College ;  Physician  to  the  Children's  Hos- 
pital ;  late  Pathologist  to  the  German  Hospital,  Philadelphia,  etc. 

AN  AMERICAN  TEXT=BOOK  OF  CHEMISTRY. 

Edited  by  Herbert  M.  Hill,  Ph.D.,  Professor  of  Chemistry,  Toxicology,  and  Physics, 
Medical  Department  of  the  University  of  Buffalo,  New  York. 

AN  AMERICAN  TEXT-BOOK  OF  NURSING. 

By  American  Teachers.  Edited  by  Roberta  M.  West,  late  Superintendent  of 
Nurses  in  the  Hospital  of  the  University  of  Pennsylvania. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.D.,  Clinical  Professor 
of  Laryngology  and  Rhinology,  Jefferson  Medical  College,  Philadelphia. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Professor  of  Anatomy 
in  the  Medico-Chirurgical  College,  Philadelphia. 

PRYOR-PELVIC  INFLAMMATIONS. 

The  Treatment  of  Pelvic  Inflammations  through  the  Vagina.  By  W.  R.  Pryor, 
M.  D.,  Professor  of  Gynecology  in  the  New  York  Polyclinic. 

VECKI-SEXUAL  IMPOTENCE. 

The  Pathology  and  Treatment  of  Sexual  Impotence.    By  Victor  G.  Vecki,  M.  D. 

From  the  second  German  edition,  revised  and  enlarged. 

HOLMES-SURGERY. 

A  Manual  of  Surgery.  By  Edmund  W.  Holmes,  M.  D.,  Demonstrator  of  Anatomy 
in  the  University  of  Pennsylvania. 

JACKSON-DISEASES  OF  THE  EYE. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor 
of  Diseases  of  the  Eye  in  the  Philadelphia  Polyclinic  and  College  for  Graduates  in 
Medicine. 

NANCREDE-PR1NCIPLES  OF  SURGERY. 

The  Principles  of  Surgery.  By  Charles  B.  Nancrede,  M.  D.,  Professor  of  Sur- 
gery and  of  Clinical  Surgery,  University  of  Michigan,  Ann  Arbor. 

OGDEN-URINARY  ANALYSIS. 

A  Manual  of  Urinary  Analysis.  By  J.  Bergen  Ogden,  M.  D.,  Assistant  in  Chem- 
istry, Harvard  University  Medical  School,  Boston,  Mass. 

STONEY— MATERIA  MEDICA  FOR  NURSES. 

Materia  Medica  for  Nurses.  By  Emily  A.  M.  Stoney,  Graduate  of  tho  Training 
School  for  Nurses,  Lawrence,  Mass.  ;  late  Superintendent  of  the  Training  School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass. 

40 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below 


Form  L9-Series  493! 


VOLUMES  NOW  READY. 

Atlas  of  Internal  Medicine  and  Clinical  Diagnosis.     By 

Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A, 
Eshner,  M.D.,  Professor  of  Clinical  Medicine  in  the  Phila- 
delphia Polyclinic;  Attending  Physician  to  the  Philadelphia 
Hospital.     68  colored  plates.     Cloth,  $3.00  net. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of 
Vienna.  Edited  by  Frederick  Peterson,  M.D. ,  Clinical 
Professor  of  Mental  Diseases,  Woman's  Medical  College,  New 
York  ;  Chief  of  Clinic,  Nervous  Dept.,  College  of  Physicians 
and  Surgeons,  New  York.  With  120  colored  figures  on  56 
plates,  and  193  half-tone  illustrations.     Cloth,  $3.50  net. 

Atlas  of  Diseases  of  the  Larynx.  By  Dr.  L  Grünwald, 
of  Munich.  Edited  by  Charles  P.  Grayson,  M.D.,  Lec- 
turer on  Laryngology  and  Rhinology  in  the  University  of 
Pennsylvania  ;  Physician-in-Charge,  Throat  and  Nose  Depart- 
ment, Hospital  of  the  University  of  Penna.  With  107  colored 
figures  on  44  plates,  and  25  text-illustrations.    Cloth,  $2.50  net. 

Atlas  of  Operative  Surgery.  By  Dr.  O.  Zuckerkandl,  of 
Vienna.  Edited  by  J.  Chalmers  DaCosta,  M.D.,  Clinical 
Professor  of  Surgery,  Jefferson  Medical  College,  Philadelphia  ; 
Surgeon  to  the  Philadelphia  Hospital.  With  24  colored  plates, 
and  217  illustrations  in  the  text.      Cloth,  $3.00  net. 

Atlas  of  Syphilis  and  the  Venereal  Diseases.  *  By  Prof. 
Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton 
Bangs,  M.D.,  late  Professor  of  Genito-Urinary  and  Venereal 
Diseases,  New  York  Post-Graduate  Medical  School  and  Hos- 
pital. With  71  colored  plates  from  original  water-colors  by 
A.  Schmitson.      Cloth,  $3.50  net. 

Atlas  of  External  Diseases  of  the  Eye. — By  Dr.  O.  Haab, 
of  Zurich.  Edited  by  G.  E.  deSchweinitz,  M.  D.,  Profes- 
sor of  Ophthalmology,  Jefferson  Medical  College,  Philadel- 
phia. With  76  colored  illustrations  on  40  plates.  Cloth, 
$3.00  net. 

Atlas  of  Skin  Diseases. — By  Prof.  Dr.  Franz  Mracek,  of 
Vienna.  Edited  by  Henry  W.  Stelwagon,  M.  D.,  Clinical 
Professor  of  Dermatology,  Jefferson  Medical  College,  Phila- 
delphia. With  63  colored  plates  and  39  beautiful  half-tone 
illustrations. 

IN  PREPARATION. 

Atlas  of  Pathological  Histology.  Atlas  of  Operative  Gynecology. 

Atlas  of  Orthopedic  Surgery.  Atlas  of  Psychiatry. 

Atlas  of  General  Surgery.  Atlas  of  Diseases  of  the  Ear. 


